Forum of the North Carolina Medical Board

Primum Non Nocere
N C M E D I C A L B O A R D
In This Issue of the FORUM
President’s Message:
Lessons from a Crow.....................................1
From the Executive Director:
Our Ecosystem .............................................1
Fondly, Carolyn:
Letters to a Young Physician .........................4
Dr Collman Named Part-Time Medical
Coordinator for NCMB .............................6
NCMB Elects Officers ...................................7
The Intersection of Public Health and
Pharmacy for Older Adults: Making
Sure That “Doctors’ Orders”
Can and Should Be Followed.....................8
Dr Dees Honored by Duke University
Medical Center.........................................11
NCMB Revises Two Position Statements .....11
President’s
Message
Walter J. Pories, MD
Primum Non Nocere
NORTH CAROLINA
MEDICAL BOARD
April 15, 1859
Item Page Item Page
Lessons from a Crow
They made a big deal about those two
birds. Apparently Betty and her mate were
the subjects of a test to determine whether
crows could learn how to extract meat from
a test tube with a wire. The birds were pre-sented
with two wires, one straight and the
other bent into a hook. The experiment did
not last long. As soon as the crows learned
that only the bent wire was effective, the
dominant male commandeered the tool.
Betty’s response was to bend the remaining
wire by wedging it into a crack in the cage,
adjusting it until she had a functional tool.
The folks at Oxford University are normally
quite reserved, but they were excited this
time. The observation proved that birds not
only use tools but also can fabricate them. I
didn’t think it was such a big breakthrough
because, at least on our farm, we have all
sorts of livestock who keep outsmarting us.
The more interesting aspects to the story
are that 1) Betty learned when and what she
needed to know, 2) she improved with prac-tice,
3) and her learning was measured by
outcomes.
These basic principles of education, even
applicable to crows, differ from our
approach to the continuing education of
physicians. Currently, we simply mandate
the process. In North Carolina, physicians
must document 150 hours of practice rele-vant
CME every three years in order to stay
up to date.
b) Each person licensed to practice
medicine in the State of North
Carolina shall complete no less
than 150 hours of practice relevant
CME every three years in order to
enhance current medical compe-tence,
performance or patient care
outcome. At least 60 hours shall
be in the educational provider-ini-tiated
category as defined in Rule
.0102 of this Section. The remain-ing
hours, if any, shall be in the
physician-initiated category as
Our Ecosystem
To use an analogy with nature, a medical
board is in a complex community of organi-zations
instead of organisms. This commu-nity
has a more profound impact on public
protection and the profession of medicine
than many may think. When we go out to
speak to various community groups, people
are often surprised to learn the breadth and
scope of this Board’s activities. For
licensees, unless they have been on the
receiving end of complaints or investiga-tions,
their last contact with the Board may
have been many years ago in the context of
applying for a license. This is, perhaps, not
typically viewed as a pleasurable experience
and is, thus, easy to use as a basis for formu-lating
opinions about the Board. If one
reads this Forum, of course, one gets a broad-er
understanding. To really gain insight into
the process, it would be worthwhile to
explore some of the organizations with
which we relate.
Federation of State Medical Boards
The most important, of course, is the
Federation of State Medical Boards of the
United States (FSMB). Founded in 1912,
this is an organization of all the medical
boards in the United States. It has also
extended affiliate membership to similar
licensing authorities in several other coun-tries.
The Canadian provinces and the
Federation of Medical Licensing Authorities
of Canada hold affiliate membership. The
FSMB is based in Euless, Texas, near Fort
Worth. Its mission is continual improve-ment
in the quality, safety, and integrity of
health care through the development and
promotion of high standards for physician
licensure and practice. The most valuable
continued on page 3
continued on page 2
Is Your Attitude Getting in Your Way? .........12
Physician Behavior .......................................14
Social Services for Pregnant and
Parenting Adolescents ..............................17
The Importance of Verifying the
Licensure Status of Nurses Employed
in Office-Based Practices ..........................18
As Stewards of the Medicaid Budget,
We Can Do Better! ..................................19
etc etc etc .....................................................19
Board Actions: 5/2002-7/2002 ...................20
Board Calendar ............................................24
Change of Address Form .............................24
No. 3, 2002 forumFondly, Carolyn: Letters to a
Young Physician, Part III - page 4
From the
Executive
Director
Andrew W. Watry
The Forum of the North Carolina Medical Board is published four times a year. Articles appearing in the Forum,
including letters and reviews, represent the opinions of the authors and do not necessarily reflect the views of the
North Carolina Medical Board, its members or staff, or the institutions or organizations with which the authors are
affiliated. Official statements, policies, positions, or reports of the Board are clearly identified.
We welcome letters to the editor addressing topics covered in the Forum. They will be published in edited form
depending on available space. A letter should include the writer’s full name, address, and telephone number.
North Carolina Medical Board
Raleigh, NC forum N C M E D I C A L B O A R D
Vol. VII, No. 3, 2002
Primum NonNocere
NORTH CAROLINA
MEDICAL BOARD
April15, 1859
Primum Non Nocere
2 NCMB Forum
Walter J. Pories, MD
President
Greenville
Term expires
October 31, 2003
John T. Dees, MD
Vice President
Bald Head Island
Term expires
October 31, 2003
Charles L. Garrett, Jr, MD
Secretary-Treasurer
Jacksonville
Term expires
October 31, 2002
George C. Barrett, MD
Charlotte
Term expires
October 31, 2002
E.K. Fretwell, Jr, PhD
Charlotte
Term expires
October 31, 2002
Hari Gupta
Morrisville
Term expires
October 31, 2004
Stephen M. Herring, MD
Fayetteville
Term expires
October 31, 2004
Robin N. Hunter-Buskey, PA-C
Gastonia
Term expires
October 31, 2003
Elizabeth P. Kanof, MD
Raleigh
Term expires
October 31, 2002
Robert C. Moffatt, MD
Asheville
Term expires
October 31, 2004
Michael E. Norins, MD
Greensboro
Term expires
October 31, 2004
Aloysius P. Walsh
Greensboro
Term expires
October 31, 2003
Andrew W. Watry
Executive Director
Bryant D. Paris, Jr
Executive Director Emeritus
Publisher
NC Medical Board
Editor
Dale G Breaden
Assistant Editor
Shannon L. Kingston
Address
1201 Front Street, Suite 100
Raleigh, NC 27609
Telephone
(919) 326-1100
(800) 253-9653
Fax
(919) 326-1130
Web Site:
www.ncmedboard.org
E-Mail:
info@ncmedboard.org
Lessons from a Crow
continued from page 1
defined in Rule .0102 of this
Section.
The rule misses the mark. Can we assess
a baker by the number of hours he spent
reading a cookbook? Even so, it is certainly
not a demanding requirement. Attending
one meeting a year and reading about an
hour every two weeks fulfills the rules. Most
doctors do far more. They may read for
hours trying to find the right treatment for a
patient or to learn new health care rules.
The CME requirement arose out of a con-cern
that doctors would not continue to
learn once they were out of residency. As if
doctors are not eager to learn! The facts
show just the opposite. Think of how rapid-ly
laparoscopy spread across the U.S. as sur-geons
attended courses by the thousands, at
significant personal expense, to learn this
new technology. Similarly, consider the
speed by which other advances crossed the
U.S., such as the insertion of cardiac stents,
endovascular surgery, new chemotherapeutic
agents, and management of arrhythmias. In
fact, the prescription of some drugs spreads
so quickly that third-party payers have to
conduct sessions to prevent their introduc-tion.
There is ample evidence that physi-cians
do not have to be forced to learn.
Bill Gates recently said that more discov-eries
were made in the last decade than in the
rest of recorded time. President Clinton put
it a little differently with his statement that
science doubles every six years. Either way,
it suggests that a 50-year-old physician, who
graduated at the age of 26, had to learn 75
percent of his current fund of knowledge
since he finished medical school. Further,
before he retires, he will need to expand his
knowledge by another 300 percent.
Fortunately, we now have better
approaches to learning than textbooks that
are often out of date by the time they are
published, erratic journal articles, and lec-tures
in far-away-places. The advent of the
Internet, the availability of inexpensive com-puter
memory, and the widespread familiari-ty
of physicians with computers allow us to
think outside the box. It is now possible to
provide full courses over the Internet based
on curricula that are stratified to meet the
needs of the individual. These courses could
be presented in modules so they can be
learned or reviewed in manageable seg-ments.
Further, it is now feasible to include
a test at the end of the course that is graded
independently to help the learner evaluate
progress.
Many of our medical schools have most of
the educational materials required for such a
venture. We could review the strengths of
each institution and, based on this survey,
assign each institution segments of a nation-al
Internet curriculum. For example, the
Johns Hopkins might be asked to provide a
full teaching module covering the diseases of
the pancreas, while the Rockefeller Institute
might be assigned the course on genetics.
With this approach, we could have a living
text that is always up to date, with a pro-gram
that would be available at any time and
wherever there is a telephone and computer.
Further, successful completion of the test in
the module could also provide documenta-tion
of learning.
Such an initiative in continuing education
would be, I think, an advance over our cur-rent
approach. It might almost catch us up
with the methods used for Betty, the crow.
_____________________
Photo of Betty the Crow reprinted with permis-sion
from Shaping of Hooks in New Caledonian
Crows by Weir, et al, Science 297, 981 (2002) fig
1. Copyright 2002, American Association for the
Advancement of Science.
E-Mail:
info@ncmedboard.org
Web Site:
www.ncmedboard.org
North Carolina
Medical Board
Betty at Work
No. 3 2002 3
Our Ecosystem
continued from page 1
aspect of the FSMB to us is its membership.
Through this organization, we interact quite
regularly with the larger community of med-ical
boards. The primary vehicle for this is
an annual meeting held in April. We serve
on various FSMB committees, and the year
before last the elected president of the FSMB
was one of our Board Members, George C.
Barrett, MD. This organization is far and
away the most influential national organiza-tion
to coordinate licensure standards
among the states. Beyond this, it adminis-ters
the uniform physician licensing exami-nation
(the United States Medical Licensing
Examination) and provides other valuable
services. A brief sample follows.
Examination Services: In cooperation with
the National Board of Medical Examiners,
the FSMB created and administered the first
uniform licensing examination, known as
the Federation Licensing Exam (FLEX),
which was adopted by all but one of the
states. This was the precursor to the pre-sent-
day United States Medical Licensing
Examination (USMLE), the three steps of
which were introduced between 1992 and
1994. This is one of the finest examinations
in the examination marketplace, setting the
benchmark for psychometric standards. The
USMLE very effectively tests graduates of
both U.S. and foreign medical schools for
knowledge, skills, and abilities necessary to
safely practice medicine in the United States.
Additionally, there is an osteopathic exami-nation
administered by the National Board
of Osteopathic Medical Examiners.
Membership: In addition to 68 U.S.
boards (some states have separate medical
and osteopathic boards, and the boards of
the District of Columbia, Puerto Rico,
Guam, and the Virgin Islands are included),
the FSMB interrelates with many other key
players to be described later, including the
American Medical Association, the
Association of American Medical Colleges,
the American Osteopathic Association, the
National Board of Medical Examiners, the
Educational Commission for Foreign
Medical Graduates, the Accreditation
Council for Continuing Medical Education,
the National Commission on Certification
of Physician Assistants, and others.
Post-Licensure Assessment System: The
FSMB has developed a post-licensure assess-ment
system to deal with those who have
deficits in clinical skills and clinical perfor-mance
identified by medical boards. There
are essentially two components: (1) a special
purpose examination known as SPEX, and
(2) an assessment center that started out in
Colorado but now has evolved to test sites in
Texas and Philadelphia. This is a support
service for medical boards.
Credentials Verification Service (FCVS):
This is a service to greatly facilitate interstate
mobility of physicians by providing a central
repository of core medical credentials. This
is, therefore, a major service to medical
boards and the public served by these
boards. Having individual applications for
licensure in each state that require revalida-tion
of the same core credentials is redun-dant—
a holdover from years ago. The
FCVS provides a uniform, core-credential
verification system accepted in 47 states,
including ours, that provides an alternate
pathway for licensees who are highly mobile
from an interstate perspective. Six medical
boards require FCVS for licensure appli-cants.
It is particularly helpful to foreign
medical graduates who may have difficulty
obtaining core medical credentials each time
they move from state to state.
Other Activities: The FSMB maintains a
physician data center, collecting licensure
data from all states. It maintains a board
action data bank that receives disciplinary
data from the state boards in real time and
disperses it to other states immediately. This
limits a disciplined physician’s opportunity
to relocate or seek a license in another state
without that state knowing about his or her
disciplined status. Other FSMB activities
include educational offerings at annual meet-ings
and regional meetings, publications,
on-line resources, and the FSMB’s Web site
at www.fsmb.org. The FSMB also represents
medical board concerns before the Congress.
Here are examples of recent legislation mon-itored
at the Federal level: medical error leg-islation
(HR 4889 & 2590) and the Health
Care Safety Net Improvement Act (HR
3450). Each year, there are more and more
pieces of proposed legislation at the
Congressional level that impact licensing
boards. Also, the FSMB monitors legislative
trends within the states and feeds this infor-mation
back to the membership.
Education Commission for Foreign
Medical Graduates (ECFMG)
The ECFMG began issuing certificates in
1958. Its principal customers at that time
were post-graduate training programs in the
United States that were accepting graduates
of foreign medical schools. It provided a
basis for uniform credentialing of foreign
medical graduates through a process with
three elements: an English competency
examination; a basic medical competency
examination; and a credentials check. The
ECFMG process has steadily evolved, elimi-nating
redundancies and enhancing public
protection. The medical competency por-tion
of its certification process is now a part
of the USMLE, thus limiting redundancy. It
also requires clinical skills assessment involv-ing
standardized patients. This issue
addresses the disparity between training at
foreign medical schools and that in LCME
and AOA approved facilities, identifies com-munication
problems, and surfaces problems
that could not otherwise be detected
through multiple choice tests. It also admin-isters
a test of English as a foreign language.
National Board of Medical
Examiners (NBME)
The NBME has been in existence since
1915. It was founded by the FSMB, the
American Medical Association, and other
interested medical groups and has vast and
experienced psychometric resources for
examination development. It developed the
National Board of Medical Examiners exam-ination,
which was the precursor to the
USMLE for graduates of U.S. medical
schools. Graduates of foreign medical
schools did not have access to this examina-tion
and, therefore, principally took the
FLEX. The FLEX was developed in coop-eration
with the NBME. The examinations
were, therefore, quite similar and included
many examination items from the same item
pool. The uniform examination that finally
developed, the USMLE, eliminated any of
the minor discrepancies existing between the
two prior examination pathways. The
NBME also provides the expertise for other
testing instruments, including the SPEX,
mentioned earlier, and instruments in use for
clinical skills and post-licensure assessment.
Administrators in Medicine (AIM)
AIM is a national organization of medical
board executives formed in 1983. The pur-pose
of this organization is to develop and
achieve administrative excellence for medical
board executives. It augments but does not
compete with the services of the FSMB. Its
Web site is at www.docboard.org.
Conclusion
In conclusion, the North Carolina
Medical Board needs to work closely with
these other organizations in order to provide
optimal services to the citizens of this state.
In many cases, the Board has established a
track record of leadership in these national
organizations. The executive leadership of
the FSMB and the ECFMG is in the hands
of two former North Carolinians—James N.
Thompson, MD, and James A. Hallock,
MD, respectively. This is the second time
the FSMB’s executive leadership has been
connected to this state. Bryant L. Galusha,
MD, a Charlotte pediatrician and former
president of the North Carolina Medical
Board, was the FSMB’s executive vice presi-dent
from 1984 to 1989. Our support
of these organizations reflects continuing
commitment to the public mandate of the
Board.
4 NCMB Forum
continued on page 5
Fondly, Carolyn:
Take Time to Use Your Manners
Dear W:
Your “new” car sounds exciting and—
what shall I say—challenging! Are you sure
it was a good idea to buy a 15-year-old car
that was totaled? Well, I will hush now
because I know you know something about
cars and I don’t. Maybe it wasn’t totaled too
badly. I know it didn’t take much for the
insurance company to consider my last car
totaled because by that time the poor old
thing was barely rolling anyway! Shortly
before that, I had a flat tire on that car, and
the service station attendant took one look at
the car and at me and judged that we were
not worth being nice to. In fact, he was rude
and sarcastic. Three or four days later, I was
on my way home in the evening and got
paged to please come back to the hospital to
see a five-year-old girl with new-onset
seizures. Her parents were deeply scared by
what had happened to their daughter. As I
spoke with the mother and child, the father
faded into the shadows. I finally recognized
him as the service station attendant, and he
apologized for his previous discourtesy, say-ing:
“I’m so sorry, ma’am, I didn’t know you
were anybody who mattered.” After a
moment of internal conflict, grace prevailed
and I assured him all was forgiven and that
Carolyn E. Hart, MD
Dr Carolyn E. Hart, who practices neurology in
Charlotte, is president of the Mecklenburg County
Medical Society. In place of the usual president’s com-ments
in the Society’s publication, Mecklenburg
Medicine, she has prepared a series of letters to a med-ical
student, “W,” whose parents are physicians and
friends of hers. Her thoughts, so clearly and simply
expressed, unfold as a primer of sorts, laced with
insight and wisdom, a gentle and conversational guide
and reminder for health care professionals at any point
in their careers. We thank Dr Hart and
Mecklenburg Medicine for allowing us to present the
letters here. We will publish ten letters in all over this
year. Five were published in our first two numbers of
2002 and three more appear here to continue the
series.
Letters to a Young Physician
Part III
it would not affect my care for his daughter.
The characters’ roles in this true story could
very well have been reversed. The doctor
could have been rude to his/her patient’s
father, an uneducated man in greasy work
clothes, and then could have needed his help
with that flat tire. Either way, lack of cour-tesy
could cause a significant problem later.
It is therefore very important for physicians
to “Take Time to Use Your Manners.”
W, I know you are already a kind-hearted
and courteous young man, but when physi-cians
get busy and tired, even the gentlest
among us may sometimes neglect their man-ners.
We may snap
inappropriately at
our staff, patients,
family, and each
other. If this ever
happens, admit it!
As soon as you real-ize
you overreacted,
apologize sincerely,
even to your
preschool child or
your young front-desk
clerk. Remember your words have a lot
of power. Physicians are usually articulate,
strong-willed, and influential over the
health, happiness, and/or livelihood of those
around us. An encouraging word from you
could change someone’s life by supporting
their college plans or life change. On the
other hand, an unnecessarily sharp word
from you could reduce someone to tears and
he or she might never forget your harshness.
Remember, first do no harm.
The nurses and other staff in your hospital
and office deserve your courtesy and respect.
They often care and work as hard as you do,
and they too help patients through tough
times. They also will support your efforts
enthusiastically as they witness your polite-ness
and kindness toward your patients.
Conversely, your patients watch how you
behave toward your staff and may decide on
this basis whether or not to trust you with
their secrets and their lives. A friend of mine
walked out of her physician’s office and
switched physicians after hearing hers bark-ing
at a staff member. While wintering in
Florida, another friend needed complex
repeat angioplasty and decided to trust the
local cardiologist to do it after overhearing
the agreeable way in which he spoke with his
staff.
Our society now has some amazing tools
and toys, like cell phones, PDAs, and
portable CD/DVD players. W, you proba-bly
understand how these things work, but I
just use them, mindlessly enjoying their
magic. (I did buy a book called How Things
Work but haven’t yet found time to read it!)
The reason I mention these technical won-ders
is that they are new triggers for rude-ness
in daily life. When you are on your cell
phone in a public place, be sure to talk in a
normal voice or get a better phone. Don’t
drive and hold the phone to talk— pull over
or get an earpiece so both hands are on the
steering wheel. If someone is talking with
you, don’t bury your head in your PDA,
showing him the top of your head and not
your eyes. Don’t stay on the Internet during
family mealtimes or past bedtime. These
tools are fascinating, but people are even
more so.
Old-fashioned etiquette is important, too.
Look people in their eyes and shake their
hands when you meet them. Most staff and
patients already know you are a doctor, so
you usually don’t need to say “I’m Dr. G”;
just say “I’m WG.” You also don’t need to
put MD on your checks, license plate, or sta-tionery.
Let your staff and patients know at
least a little about yourself, but not too
much; it can be good to keep a distinction
between personal and professional parts of
your life. Ask about people’s lives and inter-ests,
make notes and ask again the next time
that you see them. Keep a collection of inex-pensive
congratulations and sympathy cards
to send your patients and others in grief or
in response to graduation and wedding
announcements. Except in crowded corri-dors,
nod or say “Good morning” or “Good
afternoon” to everyone you pass. Those
golden expressions, “please,” “thank you,”
“I’m sorry,” “would you,” and “could you
please,” are still very potent and almost
always get a positive result.
Remember what my service station atten-dant
learned and treat everybody as if they
were “somebody who mattered.” God,
through several of the religions of the world,
has given us the Golden Rule. He has also
set up our cellular aging processes such that
by midlife, our facial lines show a lot about
our personalities. My grandmother
explained it succinctly, saying: “At 40, you
get the face you deserve!” So, keep an eye
on the mirror over the next couple of
decades, W, to see if you are still remember-ing
to “Take Time to Use Your Manners”!
Good luck with that car!
Fondly,
Carolyn
“When physi-cians
get busy
and tired, even
the gentlest
among us may
sometimes
neglect their
manners”
No. 3 2002 5
continued on page 6
Fondly, Carolyn
continued from page 4
Take Time to Be Culturally
Competent
Dear W:
¿Que pasa? How was your trip to Mexico?
I hope you, your brother C, and your folks
had a great time. I have a feeling that may
be your last trip together as a family since
you and C have such busy schedules of your
own now. It was too bad B couldn’t join
you; I’m sure she missed you a lot. Did you
get to do any dancing? You know your
father, BG, is very good at the Texas Two-
Step, and he taught it to me. It somehow
reminded me of Cajun dancing and also of
clogging and polka. Isn’t it intriguing how
different cultures sometimes have such simi-lar
dance styles and, for that matter, music,
customs, and beliefs? You are such a curious
and enthusiastic young man, W, I know you
will enjoy exploring our world and learning
about other cultures. That will help make
you a better physician because it is very
important for physicians to “Take Time to
Be Culturally Competent.”
Striving to understand other cultures is
not only a compassionate and educational
exercise for physicians to undertake but is
becoming increasingly necessary to properly
care for our patients. Did you know that the
U.S. Census Bureau anticipates that in the
next five years 48 percent of U.S. residents
will be from cultures other than “white/non-
Hispanic”? By the year 2050, Hispanics are
expected to comprise 24.5 percent of the
U.S. population, and African Americans,
currently the largest minority, will constitute
15.4 percent of U.S. residents (Salimbene).
Other major minority groups include Asians
(currently about 3.4 percent), Middle
Easterners, American Indians, and emigrés
from former Soviet Bloc countries, especial-ly
Yugoslavia (Bosnia) and Poland. Within
each of these groups, there are subsets based
on age, gender, religion, sexuality, etc, and
the perspectives of these subsets and of indi-viduals
may differ from each other dramati-cally.
It is very important to learn about other
cultures, but not to make assumptions about
individual patients based on their nation or
culture of origin. This is the difference
between generalizing and stereotyping. It is
reasonable to use generalizations learned
about a culture or country in order to focus
on a patient’s potential beliefs or perspec-tives,
but not to stereotype the patient.
Often, it is helpful to ask the patient about
his/her foods, beliefs, family, and health
practices. A handbook about cultural differ-ences
can also be useful. The best that I have
found are What Language Does Your Patient
Hurt In? A Practical Guide to Culturally
Competent Patient Care, by Suzanne
Salimbene, PhD, (2000, ISBN
1883998247, 1-800-865-5549); and Pocket
Guide: Cultural Assessment, by Elaine
Geissler, PhD, (1999, 2nd Ed., ISBN
0815136331, www.us.elsevierhealth.com).
Both of these are excellent and describe
proper ways of addressing patients, touching
patients, collecting and conveying informa-tion,
reaching decisions, and understanding
differing con-cepts
of space,
time, and caus-es/
cures of ill-ness.
Although
these books are
enlightening, it
may be fun to
learn about other
cultures by expe-riencing
them
through travel
(perhaps a med-ical
work trip?),
music (Yo Yo Ma’s new CD, Silk Road
Journey, is a wonderful product of many cul-tural
influences), and food. I would also rec-ommend
listening to National Public Radio
and viewing the Public Broadcasting
System, exploring on the Internet (try
www.omhrc.gov and magma.national-geo-graphic.
com), and reading (try When I Was
Puerto Rican, by Esmeralda Santiago;
Monkey Bridge, by Lan Cao; The Spirit
Catches You and You Fall Down, by Anne
Fadiman; and Aman: Story of a Somali Girl,
by Virginia B. Lee). The best and most
enjoyable exploration method of all is to
simply chat with your patients, staff, and
neighbors from other cultures.
As our society has digested the news of
the 9/11/01 attacks and subsequent events,
some of our innocent Middle Eastern immi-grants,
sadly, have felt the backlash of our
shock. There have been some shameful
examples of stereotyping, though several
positive developments have also occurred. I
believe we have felt more patriotic gratitude
for daily freedoms, deeper respect for our
protectors, and a heightened awareness of
the rest of the world beyond our borders.
We have been jolted into a “frightened
eagerness to know about the ‘other’ world,”
according to Edward Brynn, director of
International Programs at UNC Charlotte,
in a recent interview with The Leader.
Charlotte now has international information
and support services (www.charlottemic.org/
resource.htm), and many Charlotteans are
learning or reviewing Spanish or other lan-guages,
demonstrating a welcoming attitude
toward these newcomers. I mentioned a
couple of months ago that I have been learn-ing
Spanish by listening to tapes and using a
CD-ROM program, but my young patients
have been my best instructors. At each visit,
I ask them to teach me to say something in
their language.
W, you are a lucky fellow to be bilingual
and to have such familiarity with the
Hispanic immigrants and American Indian
communities near your Southwest home.
Having grown up in an integrated mountain
community in South Carolina, I thought I
was similarly familiar with African-American
culture but have come to realize that there is
remarkable diversity among African-
Americans’ beliefs, backgrounds, and prac-tices.
Although most African-Americans
help define “mainstream” American culture,
others are of very different and unfamiliar
backgrounds.
Many ethnic groups have traditional or
folk healing methods that may be helpful,
neutral, or harmful. I remember that you
and your mother, L, have worked with some
of the American Indians in New Mexico and
Arizona. Did you have any chance to learn
of their folk healing methods?
W, I am sorry this letter is a little longer
than most, but cultural diversity is one of my
favorite topics. You have a cheerful and
inquisitive nature, and I know you will con-sider
the project of learning about other cul-tures,
not as a physician’s obligation to his or
her patients, but as a fun, lifelong explo-ration
of the amazing mosaic of our world.
Remember to “Take Time to Be Culturally
Competent” and have fun doing so! Hasta
la proxima mes!
Fondly,
Carolyn
Take Time to Live Healthily
Dear W:
I’m sorry to hear that you got mycoplas-ma,
and I hope you are starting to feel better
now. I had mycoplasma once during resi-dency
and remember that uncontrollable
cough. The doctor at the employee health
center paged me and asked me how much I
smoked because the chest X-ray showed a
large tumor with several lytic bone lesions.
This was not an optimal way to hear such
scary news, and your mom was very sup-portive.
Since I’m still here to tell the story,
you know the ending was happy (for me). I
never smoked, and the names on the chest X-rays
had just gotten mixed up! On the pos-itive
side, that experience helped me focus
“Striving to under-stand
other cul-tures
is not only a
compassionate and
educational exer-cise
for physicians
to undertake but is
becoming increas-ingly
necessary”
6 NCMB Forum
on how to live fully and provided me with a
great example of how not to convey bad
news to a patient!
As you start feeling better, W, don’t forget
to finish all your doses! You know doctors
are not known for being very good patients!
Surely between B and your folks, you will be
coerced into taking your meds and also rest-ing
properly!
This month is the anniversary of the
vicious 9/11/01 attacks, and we are all still
bruised. I can’t tell you how many kids I
have seen this year with increased headaches,
sleep problems, and other signs of stress.
Many doctors have spent a lot of time since
last September trying to comfort our
patients, and I thought perhaps it was time
to write about how we must take care of
ourselves as well. To be a good physician,
W, you will need to “Take Time to Live
Healthily.”
JA, a local obstetrician, says that five
things are required for a healthy and happy
life: trust in a higher power, a calling, a lov-ing
relationship with another adult, an avo-cation,
and exercise. In order to live health-ily,
a physician must look after his/her mind,
body, and spirit. W, you seem to me to be
faring well in all three spheres, but it is easy
to get “out of shape” in any of them. It is a
healthy exercise to take an inventory of each
area occasionally, recognizing your strengths
and acknowledging your weaknesses. Both
were conferred on us by a higher power, and
together they make us the special but quirky
individuals we are.
Physicians tend to have fairly healthy
minds, learning easily and often delighting
in mental challenges. Nevertheless, we often
have ADHD, learning disabilities, or other
imperfections that cause frustrations in our
daily lives and inconsistencies in our perfor-mance
patterns. Contrary to popular belief,
these conditions can occur in bright, accom-plished
adults (see www.chadd.org and
www.ldanatl.org). People with an undiag-nosed
neuropsychiatric condition sometimes
resort to self-medicating with alcohol or
other substances, often leading to more seri-ous
problems. Substance abuse causes huge
problems in our world, and physicians and
our families are certainly not immune. In
fact, we may be more vulnerable than aver-age
in this area, perhaps due to our pressured
schedules, independence, and reluctance to
seek help, especially for problems of the
mind or spirit. There is a lot of good help
available though, especially through
Alcoholics Anonymous (www.aa.org), the
Fondly, Carolyn
continued from page 5
North Carolina Medical Board (www.ncmed
board.org/php.htm), and Al-Anon (www.al-anon
.alateen.org). W, if you ever experience prob-lems
like this, get help! Don’t self-medicate!
W, I have never been quite sure how to
divide mind and spirit since the fields that
study them seem to overlap and since it is all
about the brain! OK, OK, I might be a lit-tle
biased! Somehow spiritual health is more
abstract, though, and is the source of happi-ness,
love, serenity, and everything else for
which I cannot describe a neural circuit!
Just as problems with attention or learning
can affect your mental health, difficulties
with anxiety, depression, anger, and lack of
trust in a higher power can damage your
relationships, self-esteem, and overall spiri-tual
health. While preparing to write you
this letter, I asked several friends for advice
on ideas that could
guide one’s life. Try
asking your friends
this; the answers are
beautiful. The answers
I received included:
“The Lord’s Prayer”;
Frost’s “The Road Not
Taken”; “Might as well
do it right”; “Slow
down, Doc, tomorrow
ain’t promised to none of us” (an employee);
“The Serenity Prayer” (www.open-mind.
org/serenity); and my own favorite,
“Desiderata” (Max Ehrmann, 1927; try
desiderata as a search word). W, I hope you
will always remain humble enough to accept
advice from your family and friends and to
seek help if you need it!
The importance of physical health seems
apparent to physicians, and yet ironically we
often neglect our own bodily health. Many
of us delay checkups and push ourselves
through long workdays, leaving little time
for relaxation, conversation, careful nutri-tion,
sleep, and exercise. Although we sleep
less (averaging about 6.5 hours) than our
predecessors (8.2 hours) a few decades ago,
at least we also smoke less, too! In an unpre-tentious
Italian restaurant in Charlotte, there
is a framed magazine advertisement pictur-ing
a Rockwellian physician and his patient
and proclaiming “More Doctors Smoke
Camels!” Let’s hope not! We have certain-ly
made progress in understanding risk fac-tors
and publicizing healthy standards
(www.health.discovery.com and www.time.com/
time/health), but we still need to remember
to eat right, sleep enough, and exercise. Live
like your grandmother is watching and “Go
outside and get some fresh air!”
Although Epicurus’ name has been mis-takenly
associated with pleasure and privi-lege
(see Epicurean magazine, www.epicurean
.com), he actually espoused a philosophy of
life very similar to JA’s recommendations for
health and happiness. Epicurus recom-mended
basic foods, shelter, and simple
clothing, but most importantly, friends and
freedom of thought. More recently, Mary
Chapin Carpenter’s song “Passionate Kisses”
provides a similar wish list for achieving
health and happiness (see www.geocities.
com/islandlyrics).
W, I hope you feel better soon! I have to
go now and call for an appointment for my
checkup!
Fondly,
Carolyn
“In order to
live healthily,
a physician
must look after
his/her mind,
body, and spir-it”
Dr Collman Named
Part-Time Medical
Coordinator for
NCMB
Andrew W. Watry, executive director
of the North Carolina Medical Board, is
pleased to announce the selection of
Mitchell S. Collman, MD, FACC, as a
part-time medical coordinator for the
Board. He joins Gary M. Townsend,
MD, JD, who came to the Board as its
full-time medical coordinator in the sum-mer
of 2000. Dr Collman is board-certi-fied
in both internal medicine and cardi-ology
and is actively practicing as a cardi-ologist
in the Raleigh area. He serves as
a clinical assistant professor in the
Cardiology Division of the University of
North Carolina School of Medicine.
A native of New York, Dr Collman
received his BS from Rensselaer
Polytechnic Institute and his MD degree
from Albany Medical College in their
combined six-year program. He then did
his internal medicine training at the
University of Michigan Medical School
and his cardiology fellowship at the
University of North Carolina.
Dr Collman also has experience as an
emergency medicine physician and acts as
a consultant for the Social Security
Administration and Medical Review of
North Carolina. He is a fellow of the
American College of Cardiology and a
member of the Wake County and North
Carolina Medical Societies.
Dr Collman will serve as an advisor to
the Board staff in areas requiring medical
expertise and facilitate the Board’s evalua-tion
of the increased volume of com-plaints,
malpractice reports, and other
matters involving issues of medical care in
North Carolina.
No. 3 2002 7
continued on page 8
Andrew W. Watry, executive director of
the North Carolina Medical Board, has
announced the Board’s election of its officers
for the coming year: John T. Dees, MD, of
Bald Head Island, president; Charles L.
Garrett, Jr, MD, of Jacksonville, president
elect; Mr Hari Gupta, of Morrisville, trea-surer;
and Stephen M. Herring, MD, of
Fayetteville, secretary. They take office on
November 1, 2002 and will serve until
October 31, 2003. (Note that the position
of vice president of the Board is eliminated
as of November 1, 2002. It is replaced by
the newly created office of president elect.)
John T. Dees, MD, President
John T. Dees, MD, of Bald Head Island
(formerly of Cary), becomes the Board’s
president on November 1, 2002, replacing
Dr Walter Pories, of
Greenville, in that
position. A family
physician, he practiced
for many years in his
native Burgaw, a rural
area of the state. He
received his under-graduate
education at
the University of
North Carolina,
Chapel Hill, and his
MD from Duke University School of
Medicine. He did his internship at
Durham’s Watts Hospital and his residency
at Duke Hospital. He is a charter diplomate
of the American Board of Family Physicians.
Besides his private practice, Dr Dees has
served, among other things, as Pender
County Health Director, chief of staff of
Pender Memorial Hospital, and medical
director of the Huntington Health Care
Center. He has rendered distinguished ser-vice
to a wide variety of professional organi-zations,
including the North Carolina
Academy of Family Physicians, the North
Carolina Medical Society, the American
Academy of Family Physicians, the Southern
Medical Association, the Wake and New
Hanover-Pender County Medical Societies,
and the American Medical Association. He
served as president of the North Carolina
Medial Society in 1991-92 and is a member
of the Society’s Executive Council and an
alternate delegate to the American Medical
Association’s House of Delegates. He has
NCMB Elects Officers:
John T. Dees, MD, President;
Charles L. Garrett, Jr, MD, President Elect;
Mr Hari Gupta, Treasurer; Stephen M. Herring, MD, Secretary
also been an active participant in civic affairs
in Burgaw and Pender County and at the
state level.
Dr Dees was first named to the Board by
Governor James B. Hunt, Jr, in 1997. While
on the Board, Dr Dees has served, among
other committees, on the Complaints
Committee, the Physicians Health Program
Committee, the Investigative Committee,
the Clinical Pharmacist Practitioner Joint
Subcommittee, and the Executive
Committee. He currently chairs the
Licensing and PHP Committees. In 2000,
he was elected secretary-treasurer of the
Board. He served as the Board’s vice presi-dent
from November 2001 through October
2002.
Dr Dees says his philosophy is that
“service to humanity is the best work of
life.”
Charles L. Garrett, Jr, MD,
President Elect
Charles L. Garrett, Jr, MD, of
Jacksonville, served as the Board’s secre-tary/
treasurer through
October 2002 and
will become president
elect on November 1.
Dr Garrett is director
of laboratories at
Onslow Memorial
Hospital; managing
senior partner of
Coastal Pathology
Associates, PA; med-ical
director and
adjunct faculty member at the School of
Medical Laboratory Technicians at Coastal
Carolina Community College; medical
examiner of Onslow and Jones Counties;
southeastern regional pathologist for the
Office of the Chief Medical Examiner of
North Carolina; and executive director of
the Onslow County Medical Society. A
native of South Carolina, he received his
undergraduate education at Wofford College
in Spartanburg, SC, and took his MD,
magna cum laude, at the Medical College of
South Carolina in Charleston.
Dr Garrett did his postgraduate training
at the Medical University Teaching
Hospitals in Charleston, South Carolina,
and a fellowship at the Medical College of
Virginia and in the Office of the Chief
Medical Examiner of Virginia. He is certi-fied
by the American Board of Pathology.
He also served in the U.S. Navy, from which
he was honorably discharged as a lieutenant
commander.
A fellow of the College of American
Pathologists, the American Society of
Clinical Pathology, and the American
Academy of Forensic Sciences, Dr Garrett is
active in a large number of professional
organizations and served as president of the
North Carolina Medical Society in 1998. He
continues his work with the Medical Society
today in several capacities and is a Society
delegate to the American Medical
Association. He is also on the Board of
Directors of the AMA’s Political Action
Committee.
Among his many other professional activ-ities,
Dr Garrett has presented a number of
papers on forensic medicine to legal groups
in North Carolina and other states. In 1998,
Governor Hunt presented him the Order of
the Long Leaf Pine. He is very active in
church and civic affairs in Jacksonville.
Appointed to the North Carolina Medical
Board in January 2001, he has been a mem-ber
of the Board’s Investigative and
Executive Committees, and chairs the Policy
and Legal Committees.
Mr Hari Gupta, Treasurer
Mr Hari Gupta, of
Morrisville, was born
in London, England,
and grew up in
Vancouver, British
Columbia, Canada.
He earned two bache-lor
of science degrees,
one in computer
science and the
other in civil engineer-ing,
from Washing-ton
State University.
Mr Gupta began his professional career as
a programmer and systems analyst in
Toronto, Canada, and soon moved on to a
consultant’s post with the Computer Task
Group in Columbus, Ohio. In 1990, he
joined SAS Institute in Cary, North
Carolina, beginning as a software developer
and then moving to applications develop-ment.
In 1996, he became consulting direc-
Dr Dees
Dr Garrett
Mr Gupta
8 NCMB Forum
NCMB Elects Officers
continued from page 7
tor for SAS Asia Pacific/Latin America, and
doubled AP/LA consulting revenues for two
consecutive years. In 2000, he assumed the
role of general manager for SAS Global
Services, building and managing a 70-mem-ber
team of software consultants based in
India and the United States.
In 2001, Mr Gupta became director of
SAS Consulting Partners, responsible for
building and managing alliances with key
SAS partners and for developing and moni-toring
guidelines for the SAS Consulting
Partner program.
He left SAS in late 2001 to develop other
business interests. He is currently pursuing
a career in residential and commercial real
estate and is working on establishing a fur-niture
import business.
Mr Gupta was appointed to the Board in
February 2002. He has served on the
Board’s Legal and Complaints Committees
and will take his position as treasurer on
November 1, 2002.
Stephen M. Herring, MD, Secretary
Stephen M. Herring, MD, of Fayetteville,
a native of Chapel Hill, North Carolina,
took his BA degree at the University of
North Carolina, Chapel Hill. He earned a
DDS from the University of North Carolina
School of Dentistry,
followed by an MD
from the Wake Forest
University/Bowman
Gray School of
Medicine. He did his
internship in general
surgery and a residen-cy
in general surgery
and plastic surgery at
Bowman Gray. He is
certified by the American Board of Plastic
Surgery and holds licenses in both medicine
and dentistry.
Currently in the private practice of plastic
surgery in Fayetteville, Dr Herring is affiliat-ed
with Cape Fear Valley Medical Center
and Highsmith-Rainey Memorial Hospital.
He is a member of the American Society of
Plastic and Reconstructive Surgeons and is
active in state and local professional organi-zations.
He is also a past president of the
Cumberland County Medical Society and
author and co-author of several journal arti-cles.
Dr Herring was first named to the Board
in 1998. He has served on several Board
committees and currently serves on the
Policy Committee and chairs the
Investigative Committee. He will assume
the position of Board secretary on
November 1, 2002. continued on page 9
Dr Herring
The Intersection of Public Health and Pharmacy
for Older Adults: Making Sure That “Doctors’
Orders” Can and Should Be Followed
Gina Upchurch, RPh, MPH
Executive Director, Senior PHARMAssist
In the age of dimin-ishing
reimbursement
for patient care and
increasing emphasis on
“productivity,” more
health care providers
are opting not to
accept new Medicare
patients. Older adults
often have multiple
chronic conditions and
are taking multiple medications, requiring
more than the allotted time for appoint-ments.
While many providers feel rushed
and dissatisfied with current reimbursement
models, the Medicare payment structure
isn’t likely to reverse direction anytime soon
given the current economic forecast and the
lack of prevention foresight.
Providers’ lack of face-to-face time with
seniors is also a growing concern for com-munity
pharmacists who are being relegated
to deciphering insurance or “discount” cards
and filling more and more prescriptions as
reimbursement rates per prescription shrink.
It is projected that annual outpatient pre-scriptions
will grow to 3.13 billion in 2002,
and sales for these medications will exceed
$188 billion.1 This comes at a time of a
national pharmacist shortage, which may be
leading to more medication dispensing
errors as the sheer volume of prescriptions
and the plethora of “discount” cards over-whelm
community pharmacists.
If this shortage of time with seniors is not
a large enough public health concern, it gets
worse. In a recent survey of seniors con-ducted
by the Kaiser Family Foundation, the
Commonwealth Fund, and Tufts-New
England Medical Center in eight states, 22
percent of all seniors surveyed said they did
not fill a prescription because it was too
expensive or that they skipped doses of their
medications to make them last longer. For
the seniors who lacked prescription cover-age,
35 percent skipped doses or did not
have prescriptions filled. Therefore, a med-ication
could have been properly prescribed
and dispensed, and yet the expected out-come
is out of reach. Even prescription “cov-erage”
is not an assurance of medication
adherence. Close to one in four seniors in
the survey (including many with prescrip-tion
coverage) reported spending $100 per
month on their medications in 2001, which
is a significant financial challenge for many
seniors with fixed, limited incomes.2
In addition to reimbursement barriers for
health care providers working with seniors,
and the inability of many seniors to afford
the medications prescribed for them, many
older adults are receiving medications they
do not need and, in fact, may be causing
harm. It is projected that for every $1 spent
paying for medica-tions
in the ambula-tory
setting in the
U.S., we spend $1.36
dealing with medica-tion-
related problems
in this same popula-tion.
3 Fortunately,
many of these prob-lems
can be avoided
when the patient,
provider, and phar-macist
work together to ensure that every-one
is on the same “medication page.”
While there are definite limitations within
the health care system that currently do not
support the comprehensive treatment of
older adults with multiple concerns, there
are, nonetheless, many providers who effec-tively
handle the issues of limited time and
of medication payment and appropriateness
to ensure high quality care for their older
patients. In this age of advanced technology,
I would like to highlight some of the issues
involved with prescribing for older adults,
along with a few inexpensive, low-tech
methods that health care providers can
incorporate into their practices to ensure
that the medications prescribed are taken
appropriately and bring more good than
harm.
Polypharmacy and Medication
Inappropriateness
In 1998, people over the age of 65 com-prised
13 percent of the U.S. population, yet
they consumed 34 percent of prescription
medicines ordered, which represented 42
percent of prescription expenditures.4 While
polypharmacy (the use of multiple medica-tions)
may be necessary and beneficial,
sometimes it is a result of a senior having
Ms Upchurch
“Many older
adults are
receiving med-ications
they do
not need and,
in fact, may be
causing harm”
No. 3 2002 9
continued on page 10
Pharmacy
continued from page 8
multiple providers and pharmacists, with no
one provider having a complete picture of all
the medications a senior may be taking,
including prescription, over-the-counter, and
herbal products. In a nationwide survey con-ducted
in 2000, community-dwelling
seniors reported filling 28.5 different pre-scriptions
on average over the course of a
year.5 Polypharmacy seems particularly trou-blesome
upon hospital discharge when the
discharge summary and prescriptions are not
written by the provider who follows the
senior in the community. Even if the regular
community provider discharges the patient,
seniors are often confused about how to
“merge” discharge medications with their
regular medications, possibly leading to
inappropriate drug regimens.
There is an increased risk of adverse effects
and drug interactions as the number of med-ications
increases. While many drug-drug
interactions are not clinically significant,
many are. In addition, there are drug-dis-ease
interactions (ie, arthritis medicines that
can worsen GERD) and drug-nutrient inter-actions
(ie, less levothyroxine absorption if
taken within a few hours of calcium) that
can negatively affect the lives of older adults.
Polypharmacy is not a prerequisite for
medication-related problems in the elderly;
one medication can decrease the quality of
life for a senior. Findings from the 1996
Medical Expenditure Panel Survey indicated
that 21.3 percent of noninstitutionalized
elderly in the U.S. received 1 of 33 poten-tially
inappropriate medications. In fact, the
study likely underestimated the “inappropri-ateness”
of medication use in the elderly, as it
only used explicit criteria developed by Beers
and colleagues (a list of 33 medications) and
did not include dosage, dosing intervals,
indication criteria, or duplicate therapy.6
While more clinical trials are beginning to
include older adults, the complexity of the
study design necessitates that seniors with
several co-morbidities taking multiple med-ications
(confounders) be excluded from
many of the studies. Unfortunately, in real
life, there are older adults with multiple
problems and pharmaceutical remedies
swirling around when new agents are added
to the mix. Post-marketing surveillance is
critical for understanding the effects of med-ications
in the elderly.
Attach to the hectic health care provider
scenario the fact that very few health care
providers have any formal training in geri-atrics
and geriatric pharmacology, and we
have a dangerous intersection where phar-macy
meets public health.
Pharmacology and Adherence with
Older Adults
Older adults differ from younger cohorts
in two major ways with regard to pharma-cokinetics.
While there is individual varia-tion
among the senior population, two gen-eralizations
remain: 1) renal function
declines with age, and 2) hepatic function
(especially Phase I metabolism) is decreased
in the elderly. Some medications that are
eliminated primarily by the kidney, which
may need to be adjusted in an older individ-ual,
even with a normal creatinine, include
metformin, digoxin, allopurinol, lithium,
and amantidine. Medications that depend
on Phase I metabolism (eg, hydroxylation,
oxidation, etc) include several of the benzo-diazepines
(eg, flurazepam, triazolam,
diazepam), making them less appropriate for
use in the elderly.
In addition, clinical experience demon-strates
that many older adults are simply
more sensitive to the effects of medications
than the younger cohorts, who are often
included in the clinical trials. The senior’s
“reserve” for avoiding adverse effects is more
limited. For example, medications with
anticholinergic side effects may be a small
nuisance to a young person (ie, dry mouth);
however, anticholinergics may significantly
impair an older person (ie, mental confu-sion,
urinary retention, constipation, ortho-static
hypertension, etc).
After a medication is appropriately pre-scribed
and dispensed, medication adminis-tration
and adherence are usually left up to
the senior and his or her caregiver.
Medication adherence is a means to an end,
not an end unto itself. Twenty years ago,
Cooper and colleagues found that seniors
were no more or less adherent than younger
adults when matched for complexity of drug
regimen. And interestingly, when older
adults were non-adherent, 90 percent of the
time they underused the medication and 73
percent of the underuse was intentional.
Many of the seniors noted that they did not
perceive a need for the medication at all or in
the dosages prescribed.7 They also cited side
effects and the growing concern that “I sim-ply
cannot afford it.” In fact, sometimes
nonadherence is justifiable and appropriate.
The key is that these circumstances need to
be exposed and, if possible, alternative ther-apies
begun that satisfy the side effect and
pocketbook profile. This can happen with
honesty, rapport, and time.
Clash Between Rising Expenditures
and Our Ability to Pay
Medication expenditures have risen at
double-digit rates during the last few years.
In 2000, 42 percent of the year’s 18.8 per-cent
rise was attributed to an increase in the
number of prescriptions written, 36 percent
was attributed to a shift to the use of more
expensive medications, and 22 percent was
due to actual price increases from the previ-ous
years.8 Approximately 10 percent of our
health care dollars are spent on medications,
but these expenditures are rising much faster
than other segments in health care. While
much has been said about the massive
increase in direct-to-consumer advertising,
roughly 50 percent of advertising dollars are
spent on medication samples of the newest
medications.9 Many providers try to help
their seniors who struggle financially by
using their sample cabinets as pharmacies. In
addition, many providers are willing to help
access medications for seniors and others
who cannot “foot their pharmacy bill” by
applying for medications via the drug manu-facturers’
patient assistance programs. These
ever-changing programs, which are manu-facturer
specific and sometimes drug specif-ic,
combined with the newer “discount”
cards, create a new level of “service” in the
providers office. With decreasing reim-bursement
and, thus, less time with patients,
many providers are reluctant to embrace the
challenge of completing additional paper-work
to ensure access to medications.
What Is a Provider To Do? Practical
Tips for Working with Older Adults
In many instances, older adults are pre-scribed
appropriate and necessary medica-tions,
and pharmacists dispense the medica-tions
correctly and provide counseling at the
pharmacy counter. However, there is anoth-er
critical partner in this scenario: the
patient. In fact, in the prescribing-dispens-ing-
administering triangle, there are at least
three people—the provider, pharmacist, and
patient—and many times, nurses, social
workers, caregivers, and others involved.
There are several ways to strengthen the pre-scribing-
dispensing-administering triangle.
1. Bear in mind that “any symptom in an
elderly patient should be considered a
drug side effect until proved otherwise.”10
Discontinue medications that are no
longer needed and be vigilant about mon-itoring
for side effects. Before prescribing
a medication, make sure that what is being
treated is not an adverse effect from
another medication.
2. Consider whether adding a new med-ication
to a senior’s regimen is necessary,
even if she or he comes with a particular
drug name in mind and even if your writ-ing
a prescription may speed up the inter-view.
Consider whether other alternative
forms of treatment (eg, smoking cessation
10 NCMB Forum
continued on page 11
counseling, nutrition counseling, Kegel
exercises, etc) or simply explaining the
benefits of not adding a drug to the cur-rent
regimen is truly “the best medicine.”
3. Educate yourself about the cost of drug
therapies and ask your patients if they are
able to afford their medications. If they
need help, consider whether there are
cheaper alternatives or other resources
that you can use to ensure that the pre-scribing-
dispensing-administering triangle
doesn’t break down because of practical
decisions that your patients have to make.
A close relationship with a community
pharmacist may prove invaluable in this
regard.
4. Adopt the geriatric mantra: “Start low
and go slow.” When prescribing a med-ication
for an older adult, a general rule is
to add one medication at a time and begin
with low doses and slowly increase the
dose as necessary. The same could be said
for withdrawing a medication with CNS
effects: slowly decrease the dose before
discontinuation.
5. Ensure that accurate labels are on pre-scription
bottles. If you change the dose
or directions for administration, write a
new prescription. This will help the
senior or caregiver who may struggle to
remember the myriad of directions. In
addition, it will allow the pharmacist to
correctly counsel the patient, thus rein-forcing
the intended use of the medication
rather than serving to confuse.
6. Place the indication for the medication
on the prescription if at all possible. This
will help the patient and pharmacist
understand the use of the medication.
The pharmacist cannot type the indication
for a medication on a label (even if it is
obvious) unless the indication is on the
prescription. Seniors on multiple medica-tions
may have a difficult time remember-ing
the indications for their medicines
without help from the labels.
7. Write both the generic and brand name
of a medication on the prescription (and
label) to help prevent duplicate therapy,
especially when multiple providers and
pharmacies are involved.
8. Ask all of your patients to carry a list of
all their medications, including prescrip-tion,
over-the-counter, and herbal prod-ucts,
with them at all times. In addition,
ask your patients to show this to any and
all providers before anything gets added
to the list. Adding past medication aller-gies,
adverse effects, and the names of cur-rent
providers and pharmacies can be very
beneficial.
Pharmacy
continued from page 9
9. Ask open-ended questions about med-ication
administration and have “show
and tell” with medicines to ensure proper
medication schedules and administration
techniques. “You take this twice a day—
right?” may elicit a very different response
than, “Tell me how you actually take your
blood pressure medication.”
10. Try to determine if older adults are
included in the drug clinical trials you
review and, if so, consider whether the
study population is similar to the people
you treat.
11. Simplify drug regimens as much as
possible. Can “take the medication every
six hours” be changed to “take after each
meal (after you have checked that they do
indeed eat three times a day) and before
bedtime”?
At times, the barriers to providing good
medical care to older adults, including time,
costs, and other resources, can seem over-whelming
to the busy health care provider.
While most of the ideas on this list sound so
simple, incorporating them into practice can
make a major difference. Given that many
senior “encounters” are short on time, but
vast in need, your willingness to be attentive
to medication problems and costs can drasti-cally
improve the lives of your “chronologi-cally
gifted” patients.
_____________________
References
1. National Association of Chain Drug Stores
Weekly Report, 8/26/02.
2. The Henry J. Kaiser Family Foundation, The
Commonwealth Fund, Tufts-New England
Medical Center. Seniors and Prescription Drugs:
Findings from a 2001 Survey of Seniors in Eight
States. A Report, July 2002.
3. American Society of Consultant Pharmacists.
Seniors at Risk: Designing the System to Protect
America’s Most Vulnerable Citizens from
Medication-Related Problems. A Report, March
2002.
4. Families USA. Cost Overdose: Growth in Drug
Spending for the Elderly, 1992-2010. A Report, July
2000.
5. HealthDesk Survey (sponsored by Newshour
and Henry J. Kaiser Family Foundation),
September 2000.
6. Zhan C, Sangl J, Bierman AS, Miller MR,
Friedman B, Wickizer SW, Meyer GS. Potentially
Inappropriate Medication Use in the Community-
Dwelling Elderly. JAMA, 2001: 286(22):2823-9.
7. Cooper JK, Love DW, Raffoul PR. Intentional
Prescription Nonadherence (Noncompliance) by
the Elderly. JAGS, 1982;30(5):329-33.
8. National Institute for Health Care
Management (NIHCM) Research and
Educational Foundation. Prescription drug expendi-tures
in 2000: the upward trend continues. A
Report, 2001.
9. The Henry J. Kaiser Family Foundation.
Prescription Drug Trends—A Chartbook Update. A
Report, November 2001.
10.Gurwitz J, Monane M, Monane S, Avorn S.
Brown University Long-Term Care Quality Letter,
1995.
Senior PHARMAssist is a community-based,
nonprofit organization in Durham
County that complements the work of busy
providers and community pharmacists and
addresses many of the issues raised in the
previous article. The program was designed
to help seniors with incomes just above
Medicaid eligibility remain as active and
independent as possible for as long as possi-ble.
Since June 1994, Senior PHARMAssist
has helped over 900 seniors in Durham
directly with medication management, pre-ventive
health measures, and financial assis-tance
with their medications. An evaluation
published in the North Carolina Medical
Journal demonstrated that 30 percent more
participants knew the indications for their
medications, 29 percent fewer participants
stayed overnight in hospitals, and 31 percent
fewer participants visited emergency rooms
after being enrolled in Senior PHARMAssist
for one year.* These seniors had incomes
at or below 150 percent of the federal
poverty level (currently $1,108/single or
$1,493/couple), lived in Durham, and had
no other prescription insurance. Senior
PHARMAssist has helped an additional
2,400 individuals with either medication
management or improved access to medi-cines
via tailored referral to the drug manu-facturers’
patient assistance programs,
Medicaid, TriCare for Life, and other phar-macy
and health care programs.
Senior PHARMAssist:
• educates Durham County senior adults
about preventive health measures;
• consults with seniors and health care
providers about safe and effective medica-tion
use;
• provides financial assistance for neces-sary
medications to seniors with limited
incomes; and
• develops partnerships with others that
share its mission.
For further information about Senior
PHARMAssist see: Upchurch GA, Menon
MP, Levin KS, Catellier DJ, and Conlisk
EA. Prescription Assistance for Older
Adults with Limited Incomes: Client and
Program Characteristics. J PharmTechnol,
January/February 2002; 17:6-11. Also,
access the Senior PHARMAssist Web site at
www.seniorpharmassist.org.
NCMB Revises Two Position Statements
At its meetings in July and August 2002,
the North Carolina Medical Board complet-ed
work on and approved revisions of two of
its position statements. These revisions are
further refinements of changes made in the
same statements earlier in the year. They are
presented below in marked versions to clear-ly
indicate the changes made. Added lan-guage
has been underlined. Deleted lan-guage
has been lined through.
WRITING OF PRESCRIPTIONS
• It is the position of the North Carolina
Medical Board that prescriptions for con-trolled
substances or mind-altering chem-icals
should be written in ink or indelible
pencil or typewritten or electronically
printed and should be manually signed by
the practitioner at the time of issuance.
Quantities should be indicated in both
numbers AND words, eg, 30 (thirty).
Such prescriptions must not be written on
presigned prescription blanks.
• Each prescription for a DEA controlled
substance (2, 2N, 3, 3N, 4, and 5) should
be written on a separate prescription
blank. Multiple medications may appear
on a single prescription blank only when
none are DEA-controlled.
• No prescriptions, including those for
controlled substances or mind-altering
chemicals, should be issued for a patient
in the absence of a documented physician-patient
relationship.
• No prescription for controlled sub-stances
or mind-altering chemicals should
be issued by a practitioner for his or her
personal use. (See Position Statement
entitled “Self-Treatment and Treatment of
Family Members and Others with Whom
Significant Emotional Relationships
Exist.”)
• The practice of pre-signing prescriptions
is unacceptable to the Board.
• It is the responsibility of those who pre-scribe
controlled substances to fully com-ply
with applicable federal and state laws
and regulations. Links to these laws and
regulations may be found on the Board’s
Web site (www.ncmedboard.org).
• A physician who prescribes controlled
substances should pay particular attention
to the part of the Code of Federal
Regulations dealing with prescriptions,
which may be found at 21 CFR 1306,
entitled “Prescriptions.”
(Adopted May 1991, September 1992)
(Amended May 1996; March 2002; July
2002)
LASER SURGERY
It is the position of the North Carolina
Medical Board that the revision, destruction,
incision, or other structural alteration of
human tissue using laser technology is
surgery.* Laser surgery should be per-formed
only by a physician or by a licensed
health care practitioner working within his
or her professional scope of practice and
with appropriate medical training function-ing
under the supervision, preferably on-site,
of a physician or by those categories of prac-titioners
currently licensed by this state to
perform surgical services.
Licensees should use only devices
approved by the U.S. Food and Drug
Administration unless functioning under
protocols approved by institutional review
boards. As with all new procedures, it is the
licensee’s responsibility to obtain adequate
training and to make documentation of this
training available to the North Carolina
Medical Board on request.
Laser Hair Removal
Lasers are employed in certain hair-removal
procedures, as are various devices
that (1) manipulate and/or pulse light caus-ing
it to penetrate human tissue and (2) are
classified as “prescription” by the U.S. Food
and Drug Administration. Hair-removal
procedures using such technologies should
be performed only by a physician or by a
licensed health care practitioner working
within his or her professional scope of prac-tice
and with appropriate medical training
functioning under the supervision, prefer-ably
on-site, of a physician who bears
responsibility for those procedures. an indi-vidual
designated as having adequate train-ing
and experience by a physician who bears
full responsibility for the procedure. The
responsible supervising physician should be
on site or readily available to the person
actually performing the procedure.
*Definition of surgery as adopted by the NCMB,
November 1998:
Surgery, which involves the revision, destruction,
incision, or structural alteration of human tissue
performed using a variety of methods and instru-ments,
is a discipline that includes the operative
and non-operative care of individuals in need of
such intervention, and demands pre-operative
assessment, judgment, technical skills, post-opera-tive
management, and follow up.
(Adopted July 1999)
(Amended January 2000; March 2002;
August 2002)
No. 3 2002 11
John T. Dees, MD, a member of the
North Carolina Medical Board since
1997, was honored on October 18 by
Duke University Medical Center and
the Duke Medical Alumni Association
at a special Awards Luncheon held at
the Washington Duke Inn in Durham.
Dr Dees was one of three honorees
receiving the 2002 Distinguished
Alumnus Award. Present for the award
were Sheila Moriber Katz, MD, MBA,
President of the Duke Medical Alumni
Association; Ralph Snyderman, MD,
Chancellor for Health Affairs; and
R.C. Waters, Vice Chancellor for
Special Projects.
In their letter to Dr Dees, Dr Katz,
Dr Snyderman, and Dr R. Sanders
Williams, Dean of the School of
Medicine and Vice Chancellor for
Academic Affairs, wrote: “The leader-ship
of the Medical Center and the
Medical Alumni Association are very
proud of your accomplishments. You
have brought honor to Duke
University Medical Center as an alum-nus,
and it will be a pleasure for us to
recognize your achievements. . . .”
Dr Dees, who served as president of
the North Carolina Medical Society in
1991-92, will assume the presidency of
the North Carolina Medical Board in
November 2002.
Dr Dees Honored
by Duke University
Medical Center
John T. Dees, MD
_____________________
* Catellier DJ, Conlisk EA, Vitt CM, Levin KS,
Menon MP, Upchurch GA. A Community-Based
Pharmaceutical Care Program for the Elderly
Reduces Emergency Room and Hospital Use.
NCMJ, March/April 2000; 61(2):99-103.
Senior PharmAssist
continued from page 10
continued on page 13
Increasingly,
that is precisely
what is happening
to the relationship
between doctors
and patients.
Whatever the
underlying cause
may be, patients
are complaining
more frequently
that their physi-cians
are insensitive, arrogant, don’t listen,
are short-tempered, and simply don’t care
about the patients or their problems. Of
course, this does not happen in the majority
of the cases. The patient/doctor relationship
is as solid as ever most of the time.
However, an increasing number of com-plaints
to the Board by patients or those
responsible for them indicate that alarming
changes are occurring, both in reality and in
perception, that suggest that practitioners
are not putting enough effort into establish-ing
and maintaining their relationship with
their patients. The best technical training in
the world occurs here in the good old
U.S.A., but it goes for naught if communi-cation
with patients suffers.
Effective Communication
It has been estimated that approximately
90 percent of our communication is non-verbal,
and that highly effective people
spend a significant amount of time and ener-gy
listening (Covey, 1989). Many psycholo-gists
also feel that the ability to listen and
understand is one of the highest forms of
intellectual behavior.
It has been estimated that during her or
his average career, a physician/practitioner
will have over l00,000 visits with patients.
Obviously, what takes place most of the time
in those encounters is conversation.
However, the automatic assumption that
conversation is communication must be
tempered with the realization that, although
we say we are listening, we are likely rehears-ing
in our heads what we are going to say
when the other party is finished talking.
The effective listener must acquire the skill
of focusing on the patient and concentrating
on the verbal and nonverbal aspects of what
the patient is trying to communicate.
Unfortunately, although more medical
schools are offering courses in communica-tion
skills, this is still a difficult task. The
physician is frequently challenged to diag-nose
difficult cases with very limited infor-mation,
particularly if there is a language
barrier added to the equation. Under the
circumstances, in such situations, it’s
remarkable that we do as well as we do,
given the likely complications in communi-cations
that occur on a day to day basis.
The Other Person’s Footsteps
There have been several articles offered in
the Forum over the years aimed at helping to
reduce the incidence of complaints, but in
the complicated dynamics of today’s practice
it is increasingly difficult to meet the pres-sures
of the tight schedules, cultural differ-ences,
etc, and still keep patients contented
and feeling welcome and well-informed.
A short time ago, I happened on a film on
television titled “The Doctor.” It told the
story of a successful physician who was so
busy in his practice, and so wrapped up in
his own pursuits, that he lost sight of the
need for relating to his patients and col-leagues.
He became insensitive, abrasive,
and even arrogant in his outlook, and his
relationships suffered accordingly. Sound
familiar?
Then the doctor was stricken with cancer.
As he suffered through his illness, he started
out as a terrible patient, but he gradually
learned through his personal experience
what illness was like from the patient’s per-spective.
Fortunately, he survived and even-tually
recovered completely. He also went
through a profound transformation in his
own outlook and attitude. He found that
his subsequent encounters and relationships
with his patients, colleagues, and students
were similarly transformed. The insensitivity,
abrasiveness, and arrogance were gone,
replaced by humility, caring, and compas-sion.
I believe this film should be required
viewing for everyone, as it communicates so
eloquently the benefits of “walking a mile in
the other person’s footsteps.”
This is, of course, another example of the
Golden Rule, but in light of the number of
complaints from patients, and occasionally
from other professionals, regarding “com-munications”
problems, it prompts the ques-tion:
is your attitude getting in your way?
Communication and Complaints
As a member of the Board’s Complaint
Committee, I’m privileged to see firsthand
the complaints we receive about our
Is Your Attitude Getting in Your Way?
Aloysius P. Walsh, Chair
NCMB Complaint Committee
licensees, complaints that regrettably are on
the increase. There are a number of reasons
for this increase, of course, including
patients’ growing desire to participate in
treatment decisions and their willingness to
question and to challenge. And there is an
increasing awareness of the complaint mech-anism
open to them, easily available by call-ing
the Board or visiting the Board’s Web
site at www.ncmedboard.org. However, a very
substantial portion of the increase is due to
communications issues, including insensitiv-ity,
rude staff members, unwillingness to lis-ten,
abrasiveness, and even arrogance on the
part of the practitioner or physician. These
are the types of complaints that can be virtu-ally
eliminated. An ego suppressant, an infu-sion
of compassion, and a large dose of
humility is a great place to start.
Although many practitioners are gifted
with the characteristics that constitute what
we call a good “bedside manner,” for those
lacking the requisite gifts, there is a shortfall
in the amount of train-ing
to acquire the
skills aimed at filling
the gaps. Training in
communications, sen-sitivity,
etc, is readily
available, of course,
but it is not always
included in full mea-sure
in our medical
education programs,
nor is it sought out by
those who may be in the greatest need of
developing those skills, particularly those in
denial! Denial is frequently due to an atti-tude,
and attitude is a choice.
There are any number of articles in med-ical
and legal journals that speak to commu-nications
problems as a leading cause for
complaints and malpractice suits, and the
development of a good bedside manner
tends to have an insulating and even a reme-dial
effect, though it is not a sure cure. The
acquisition of a skill must be accompanied
by the right attitude to be effective in the
long term.
Staff Involvement
Involving one’s staff in the process of
developing and maintaining good patient
relationships also calls for considerable lead-ership.
Employees should be made fully
aware of the importance of good communi-
Mr Walsh
“The ability to
listen and
understand is
one of the
highest forms
of intellectual
behavior”
12 NCMB Forum
Your Attitude
continued from page 12
cations with patients. Self-improvement and
advancement opportunities should reflect
that commitment. Clear lines of communi-cation,
including a path for feedback with-out
fear of reprisal, should be in place to
assure communications in the office are
effective in supporting communications
with patients. Staff should be kept well
informed about practice matters and what is
expected of them; and regular performance
evaluation of staff should include a signifi-cant
communications element. Remember,
from the patient’s perspective, staff attitude
reflects practice attitude.
The practice that is focused on the well-being
and satisfaction of the patient stands a
much better chance of success. Patient sur-veys,
conversations
with patients that
include empathic
listening, and seek-ing
patients’ input
(not just telling
them what you
want them to do)
are much more like-ly
to result in a con-tented
patient.
Remember, com-munications
is a two-way process involving
both sending and receiving. Simply listen-ing
is probably the best single thing you can
do, particularly with an angry patient who
mostly needs to let off some steam. If he or
she feels you’re really interested, a potential-ly
explosive situation can often be defused.
Responding with hostility or defensiveness
practically guarantees a similar reaction from
the patient. Whatever the situation, your
own negative reaction really reflects your
own weakness, and suggests a lack of humil-ity
on your part.
Less Talking, More Listening
Various authors have offered helpful hints
over the years for more effective listening.
Davis (1967) suggested that, first, you stop
talking, show that you want to listen,
empathize, be patient, stop talking, hold
your temper, go easy on argument and criti-cism,
ask questions, and, last, stop talking.
DeMare (1968), among other things, fur-ther
suggests that you put the speaker at
ease, hear the patient through, be prepared
on the subject, make allowances for circum-stances,
avoid getting sidetracked, summa-rize
basic ideas, and restate the substance of
what you have heard. Golen(1990) also
opined that bad listeners are lazy, closed
Rate Your Listening Level
“Bad listeners
are lazy, closed
minded, opinion-ated,
insincere,
bored, and inat-tentive”
minded, opinionated, insincere, bored, and
inattentive!
Since good listening skills are more
important than ever, we offer a brief quiz at
the end of this article to help you rate your
listening level, which is key to having a car-ing
and compassionate bedside manner.
Conclusion
In closing, I would offer a couple of brief
additional suggestions. First, keep in mind
that your purpose, first and foremost, is tak-ing
care of patients, and you would do well
to park your ego in the garage or parking
lot, and make humility and compassion a
large part of your diet. Second, remember
that your patients may not recall clearly what
you say or do to them, BUT THEY WILL
NEVER FORGET HOW YOU MADE
THEM FEEL.
E-Mail:
info@ncmedboard.org
Web Site:
www.ncmedboard.org
North Carolina Medical Board
No. 3 2002 13
Do you look at the person with whom
you are speaking?
Do you withhold judgment until the
speaker is finished?
Do you like to listen to other people
talk?
Do you listen even if you do not like
the person?
Do you ask what the words mean if
you don’t know?
Do you ask questions in order to fully
understand?
Do you listen regardless of choice of
words and manner?
Do you actively think about what is
being said?
Do you put aside thought of what you
have been doing?
Do you listen equally to men, women,
young and old patients?
Do you stay aware of gestures,
inflections, and other clues?
Do you ignore distractions while listen-ing?
Do you let the speaker finish?
If the speaker hesitates, do you
encourage him/her to go on?
Do you re-state what has been said to
make certain you understand?
Do you listen even when you
anticipate what will be said?
Do you give your full attention to the
speaker?
Do you take notes while listening?
1
Never
2
Sometimes
3
Often
4
Always
How would you rate yourself as a listener? Answer the following questions by checking
the term that most accurately describes your usual behavior.
Total possible score: 72. 72-65: Artful listener. 64-59: Good listener. 58 or below:
Listening skills need work; negotiating with patients (or anyone else) is probably
difficult.
[Printed with permission from Medical Management Institute]
continued on page 15
14 NCMB Forum
Physician Behavior
Nicholas E. Stratas, MD, LFAPA
Former Member, Former President, NCMB
Over the past 35
years, the public
and medical licens-ing
boards have
paid increasing
attention to behav-ior
of physicians.
Problems with
alcohol were the
initial focus and
the term “impaired
physician” was
coined and added to our vocabulary.1 While
substance-related disorders continue to be
the major focus, there is greater recognition
of mood disorders, relational disorders, par-ticularly
marital, and behaviors that are
“boundary violations,” sometimes simply
verbal and not necessarily physical.2
Recently, another group of physicians has
been labeled “the disruptive physician.”
There is decreasing tolerance for behaviors
that now thrust the physician into reviewing
and disciplinary processes that frequently
require a psychiatric evaluation.
These behaviors are varied and include,
among others, rudeness; loud, abusive or
demeaning language; abuse of staff, patients
or relatives; sexually offensive language or
behavior; aggressive behavior; presenting to
clinical settings with alcohol on the breath.
Patients, families, office and hospital staff,
administrators, and fellow physicians, even
within the same practice, complain to vari-ous
institutional bodies including hospital
medical staff, administration, and state med-ical
licensing boards. These behaviors are
not new, but focus on them is. In the past,
they would have been excused either on the
basis of the physician being a highly valued
healer, a special member of society, or with
rationalizations such as “he must have been
up all night” or “that’s the way he is, you
know.” The public has discovered we have
clay feet, most of us sleep well at night, and
there is no longer a willingness to anoint our
narcissism with oil.
What follows is based on my personal
experience as a psychiatrist in private prac-tice
seeing, on average, over 20 physicians a
year, some self-referred, others referred for
evaluation, some from medical organiza-tions,
some from the North Carolina
Medical Board (NCMB). In addition, dur-ing
my NCMB tenure, I had the privilege of
conducting hundreds of interviews with
physicians.3,4,5 I was also fortunate to be part
bine general practice and family practice,
then psychiatry is number two. General and
family practice are overrepresented in areas
of inappropriate prescribing, inadequate
supervision of physician extenders, changes
in hospital privileges, and insufficient
medical education. Psychiatry is prominent
because of boundary violations and sub-stance
abuse. These are three-year figures
and do not include NCPHP data.
Alabama has kept figures regarding the
primary clinical diagnosis of evaluations
done. Substance abuse problems lead at 61
percent. Affective disorders are next at 29
percent and personality disorders are third at
10 percent.
Private Practice
I first came to Raleigh as one of the earli-est,
if not the earliest, with a training back-ground
in cognitive behavioral as well as
psychodynamic work. Physicians who
became aware of this sought me out either
for themselves or their families, and I have
seen them in con-sultation
for indi-vidual,
couples, and
couples group ther-apy.
10 Over the
years, physician
referrals have
increased by word
of mouth. Prior to
my appointment to
the NCMB, I was
seeing more than a
dozen physicians a
year. During my
tenure on the NCMB, physician referrals
declined. Following my tenure, I have aver-aged
over 20 physicians per year. Two-thirds
are self-referrals. The other third were
referred for evaluation and report by hospi-tal
medical staffs, practice associates, attor-neys
for physicians who were being investi-gated
either by the NCMB or their own hos-pital
staff, and by the NCMB. I have also
been consulting with physician practices
regarding organizational and practice issues.
These contacts have given me an additional
window into the life and issues of physicians
and their families. Substance abuse cases are
being diverted now to twelve-step programs
and to addictionologists.
The problems triggering referral to me
are: neuropsychiatric—(37%); marital dys-of
the origination, start-up, development,
and initial board of the North Carolina
Physicians Health Program (NCPHP). I
also served on the NCPHP’s Clinical
Committee, which reviews all cases, many
anonymously. I also cite data from
Alabama.6,7
I will focus on the “disruptive physician.”
This term is reminiscent of the time we had
pejoratives such as the “drunk doctor” for
those now identified as having “substance-related
disorders,” many of whom have dis-ruptive
behavior but are not so labeled.
When I see these doctors, I do not find them
incompetent or bent on creating havoc.
Rather, they are generally suffering narcissis-tic
injury, are hurt, defensive, frightened,
angry, and even arrogant, but hardworking
and well-meaning. They feel misunderstood
and have not had a meaningful supportive
relationship. Other than substance-related
disorders or other psychiatric conditions, the
best way to identify and understand the fea-tures
of the physicians who present with dis-ruptive
behavior is through personality
makeup. My preferred nomenclature is
Disruptive Behavior Disorder of Adulthood
(DBD).
The North Carolina Medical Board
A review of the reasons physicians were
summoned to interviews with the NCMB
and of the number of actions taken by the
NCMB reveals inappropriate prescribing
was the most frequent cause, followed in
order by substance abuse, issues of medical
competence, malpractice events, psychiatric
condition, inadequate supervision of physi-cian
extenders, patient complaints, sexual
misconduct, changes in hospital privileges,
self-prescribing, insufficient medical educa-tion,
felony conviction, and unlicensed prac-tice.
Those reasons potentially affecting
behavior—substance abuse, psychiatric con-dition,
sexual misconduct, self-prescribing,
patient complaints, and felony conviction—
comprise a total of 46 percent of interviews
and 30 percent of actions.
In North Carolina, family and general
practice and psychiatry are the specialties
with the highest probability for interview
and discipline. Emergency medicine is a
specialty with increasing numbers.
The odds ratio for likelihood of interview
and for disciplinary action identifies psychia-try
as the fourth likely to be interviewed and
the third likely to be disciplined. If we com-
“In North
Carolina, family
and general prac-tice
and psychia-try
are the spe-cialties
with the
highest probabili-ty
for interview
and discipline”
Dr Stratas
No. 3 2002 15
continued on page 16
Physician Behavior
continued from page 14
function—(30%); disruptive behavior—
(21%); quality of care issues—(10%);
chemical abuse—(2%).
In self-referred physicians, marital dys-function
and affective disorders are the most
common problems. In marital dysfunction,
the primary driving dynamics arise out of
the underlying personality makeup, with
traits of narcissism, compulsivity, avoidance,
and histrionicity predominating, in that
order. This is supported by the Alabama
data. Of the physicians referred to me for
evaluation, the largest group is that of per-sonality
traits or disorders, followed by
affective disorders.
Disruptive Behavior
Of 14 physicians referred in the past two
years because of disruptive behavior, 10 had
a primary diagnosis of personality problems,
with patterns in order of prevalence: obses-sive-
compulsive, narcissistic, avoidant, and
histrionic. In addition, three had an affective
disorder, one abused alcohol and was depen-dent.
Single, separated, or divorced physi-cians
were overrepresented.
In physicians being evaluated generally,
affective disorders, personal-ity
disorders, and chemical
dependence are the most
common diagnoses, with
marital dysfunction fre-quently
the presenting prob-lem.
In the group with “dis-ruptive
behavior,” personali-ty
problems are the most
prevalent.
When evaluating physi-cians
with disruptive behav-ior,
differential diagnoses to
be considered include: substance related;
personality disorders; adjustment disorders;
sleep deprivation; bipolar disorder; other
medical problems; and organic brain disor-ders.
Of course, more than one may be pre-sent
at the same time. Moreover, biology is
increasingly identified as a factor in person-ality
disorders.12
Early warning signals for the physician
with DBD include: being unmarried; in solo
practice; lack of involvement in medical
organizations; overwork; marital infidelity;
increased alcohol intake; legal events; prac-tice
changes; complaints/malpractice/disci-plinary
events; clinical practice changes; clin-ical
disruptions; and lack of an organizing
belief system.
Physicians’ problems show up in their pri-mary,
personal relationships long before they
impact the practice and even before the
physician may be aware of the problem.8
The career is the last place where problems
appear. Physicians in solo practice are more
vulnerable than their colleagues who are in
group or institutional practices. The latter
are more likely to be self-referrals, appear
earlier in their difficulties, and avoid discipli-nary
processes.
Physician stressors, which occur with
some frequency, include: finances/decreasing
incomes; buyouts; mergers and closures of
practices and hospitals; managed care; over-work,
unhealthy competition for jobs; and
unhealthy competition for patients. Also
stressful are declining collegiality; physician-to-
physician marriage; difficulty with inti-macy;
self-medicating; the stigma of psychi-atric
problems; and decreased satisfaction.
Vignettes
The following case vignettes are illustra-tive.
Changes have been made, of course, to
protect identities.
Doctor A was a 45-year-old male surgeon
from the eastern part of the state, twice
divorced and the father of two children. He
was referred to me by the hospital medical
staff executive committee for aggressive
behavior, abuse of hospital staff nurses, and
unorthodox techniques.
Complaints had come to the
administrator from a surgeon
colleague and surgical nurses.
The administrator turned the
case over to the president of
the medical staff.
My evaluation revealed a
hard-working physician who
had continued to keep up
with CME, who was working
long hours, in solo practice.
Two physicians had come to
his practice and then left. He was practicing
in a town with few surgeons and had
become isolated from his colleagues. His
two teenagers, living with him, were doing
well. Substance dependence was suspected
but ruled out, and the impression was of
someone with mixed personality traits of
narcissism and compulsivity with significant
relational problems.
Recommendations were for psychothera-py,
involvement with organized medicine,
monitoring of a fixed number of cases, and
review in six months. He was initially angry
and defensive. However, as I interpreted the
evaluation, bringing out the dynamic issues
and focusing on his increased efforts to
“work harder and longer” as pressures
increased, thus increasing his isolation and
unawareness of his impact on relationships,
he became tearful and in touch with his sad-ness.
He opened up and expressed his need
for help. He is following through with the
recommendations and has done well.
Doctor B was a 58-year-old, recently wid-owed
primary care physician from a rural
area of the state with two grown, married
children. She was referred because of com-plaints
by the hospital nursing staff to the
administrator about her irritability and two
episodes of coming in to the hospital with
alcohol on her breath. She had rebuffed the
administrator’s referral to NCPHP. Her
anonymity was broken and her name was
given to the NCMB. They invited her to an
informal interview and then referred her to
me for evaluation. She had an excellent his-tory,
personally and professionally, but over
time had gradually decreased professional
contacts and stopped doing hospital work.
One year earlier, her husband of 33 years
had died after several months of illness. She
was drinking more than usual, but she was
neither dependent nor an abuser. In fact, she
had most of the criteria for major depres-sion.
Her underlying personality makeup
consisted of narcissistic and avoidant traits.
She was guarded at first, but wanting to
cooperate in the treatment plan that was rec-ommended,
including goal-oriented, cogni-tive
behavioral therapy; grief work; discon-tinuation
of alcohol and caffeine; and use of
antidepressants. She did very well and is no
longer depressed. She says she has “a new
lease on life,” is golfing with her friends and
children, traveling, and reinvolved with pro-fessional
colleagues. With my evaluation
report and follow-up in hand, the NCMB
saw her again in an informal interview and
took no further action.
As an aside, I have mentioned that I did
not think Doctor B was an alcohol abuser,
although she was accused of coming to the
hospital with alcohol on her breath.
Apropos of this, I should note that one of
my most recent referrals, from his attorney
and from NCPHP, was diagnosed at Rush
Presbyterian in Chicago as an abuser of alco-hol.
They based that diagnosis simply on
the record of his coming into the hospital
with alcohol on his breath on two occasions.
He said he had used alcohol several hours
before going to the hospital on both occa-sions
to help get to sleep. He did this on the
recommendation of a medical colleague sub-sequent
to several night shifts. He has a his-tory
of minimal and appropriate alcohol use.
Doctor C, a 40-year-old, single emergency
room physician, was referred to me by his
group practice associates because of com-plaints
received from patients and nursing
staff about his brusque and short behavior
and comments. He had been the subject of
“Physicians’ problems
show up in their prima-ry,
personal relation-ships
long before they
impact the practice and
even before the physician
may be aware of the
problem”
16 NCMB Forum
Physician Behavior
continued from page 15
a lawsuit that had gone against him. Initial
interview revealed a very compulsive
detailed individual who was obsessing
about the lawsuit that had been closed two
years earlier, about a failed relationship, and,
now, about being asked to have a psychiatric
consultation. He was in a very busy practice
and evidently had not had any problems
related to quality of care. Even the case set-tled
against him was peer reviewed and his
performance was found to be appropriate.
Although he did qualify for a diagnosis of
anxiety disorder, his primary problem was
his underlying compulsive personality. He
had been in psychotherapy years earlier and,
although it was brief, he recalled it as a pos-itive
experience. He was very defensive and
protective of information about himself. He
rejected out of hand any medications, and
therapy has been brief and episodic. He is
still in practice, having had no further com-plaints,
and is still single. However, he has
joined several social organizations and has
dated a woman he met there.
Discussion
My impression is that those who are orga-nized
and structured in such a way as to suc-ceed,
and who draw attention to their suc-cess,
have been more likely to be the suc-cessful
medical school candidates. A clearer
and more objective understanding of behav-ior,
personality traits, personality disorders,
and primary mental illness in those who
select medicine as their career as compared
to the general population is needed.
Moreover, medical students need workshops
regarding predominant personality patterns
that make for success and at the same time
create vulnerabilities.11 Increased sophistica-tion
regarding psychological patterns that
promote medicine as a career, increased
attention to the human element in medical
school, awareness of the importance of per-sonal
and family support systems, a sensitiv-ity
to early signals of increased neediness—
all will allow promotion of health and bal-ance
in the physician and early detection. It
seems that medicine is attractive to those
who have overcompensated with attitudes of
uniqueness and entitlement and who seek
admiration.
Patients’ needs, played out in their posi-tive
and negative transference, interact with
the physician’s needs. Traits such as narcis-sism
and compulsivity may interfere with the
sensitivity the physician must have to the
transference phenomena that are representa-tive
of the patient’s needs.14,15 A physician’s
over-sensitivity to demands and situational
pressures and threats to status can lead to
behavior and allegations that produce hurt,
anger, and projection. The compulsive
physician works hard and, when faced with
increased pressures or questions, can become
defensive, self-focused. As a result, he or she
can end up “working harder and longer.”
It behooves us, particularly in psychiatry,
to be comfortable and competent with the
physician as patient in stepping up to advo-cacy
issues as they develop with those in
authority relationships with the physician.
We must appreciate the anger in the
referred physician, which is inevitably pre-sent,
and encourage awareness of the sadness
and even fear that is frequently repressed and
likely related to early developmental history.
Sadness is the key to narcissism and the root
of tenderness. Use of letting-go techniques
and other cognitive behavioral skills are
important for obsessional and compulsive
individuals.
At times, confrontation is very important
and needs to be timely and not delayed. It
may even be necessary in the first interview.
On many occasions, my confrontation of the
physician with the statement that a given
behavior “is unacceptable” has been the
beginning of the necessary alliance for pro-ductive
work.
Physicians as a group do better than the
general population, even when they have
presented unwillingly as the result of pres-sure
or referral from someone else. I believe
this is because they have had a lifetime of
complying with structure and expectations,
because of the peer pressure inherent in the
process of evaluation and treatment of a
physician by a physician, and because the
medical career is, in most instances, an inte-gral
part of most physician’s self-image.
Finally, times have changed and physicians
are retiring in great numbers. Identification
and assessment of those who have retired
with a successful medical career without
patient complaints, disciplinary actions, liti-gation,
or evidence of decompensation prob-ably
provide an avenue for understanding
factors that have helped them and that need
to be applied in preventive and therapeutic
undertakings with physicians.
Summary
This article is based on my retrospective
and personal experience with the NCMB
and my private practice. Concern about the
“impaired physician” has been around for a
good while, focused on chemical abuse and
dependence, now with increased acknowl-edgement
of other psychiatric syndromes,
especially the affective disorders.
Complaints have emerged regarding behav-iors
including rudeness; disrupted patient
care; loud or abusive language; using instru-ments
as weapons; abusing staff, patients or
family; and sexually offensive behavior or
language. These behaviors are predominant-ly
related to personality patterns, including
compulsivity, narcissism, and avoidance, at
times associated with primary psychiatric
problems. These personality patterns are
likely active in the selection of and success
with a medical career. Frequently, marital
relational status and counter dependence are
factors. As with all patient transactions, the
patient-doctor alliance is the key to a suc-cessful
resolution. In the main, physicians, a
group with a lifelong pattern of success, have
a significantly higher success rate than the
general population.
_____________________
References
1. Report of the Ad Hoc Committee on
Physician Impairment, Federation Bulletin
1994;81:4:229-242.
2. Report of the Subcommittee on Sexual
Boundary Violations, Federation Bulletin 1996.
3. Stratas NE, Alexander E Jr, Paris BD Jr.
Function of the Board of Medical Examiners of
the State of North Carolina, North Carolina
Medical Journal 1992;53:11-12.
4. Paris BD Jr, Stratas NE. Complaint Review
Process of the Board of Medical Examiners of
the State of North Carolina, North Carolina
Medical Journal 1992;53:15-16.
5. Newton L, Stratas NE. Review of Informal
Interviews and Disciplinary Actions of the Board
of Medical Examiners of the State of North
Carolina, 1988-1991, North Carolina Medical
Journal 1993;54:625-632.
6. Summers GL, Ford CV, Lightfoot WM. The
Disruptive Physician, I: The Alabama Recovery
Network, Federation Bulletin 1997;84:236-243.
7. Ford CV, Summers GL. The Disruptive
Physician, II: The Role of Personality Factors,
Federation Bulletin 1998;85:20-29.
8. Stratas NE. Stress and the Physician’s
Family, Kentucky Medical Bulletin, 1993; August.
9. Stratas NE. Duke University Medical
Center, Psychiatry Grand Rounds, February
2000.
10. Stratas NE. Successful Partnerships,
“Mental Health Corner,” Wake County Physician,
1997, 4:18.
11. Stratas NE. Success and Stress in Physicians,
“Mental Health Corner,” Wake County Physician,
1998, 1:19.
12. Stratas NE. Biological, Psychological or
Social? “Mental Health Corner,” Wake County
Physician, 1999, 1:8-9.
13. Stratas, NE. The Doctor-Patient
Relationship—Changing, “Mental Health
Corner,” Wake County Physician, 2000, 1:7.
14. Stratas, NE. The Physician and Narcissism,
“Mental Health Corner,” Wake County Physician,
2000, 2:6-7.
15. Stratas, NE. The Physician and
Compulsivity, “Mental Health Corner,” Wake
County Physician, 2001, 2:45.
continued on page 18
of Government. Before she could take those
steps, however, the patient left town.
This true story suggests how important a
caring physician or other health provider can
be to a young woman experiencing an
underage pregnancy and to her family—and
suggests the value of a physician knowing
something about what a DSS can offer.
Thousands of girls 17 or younger
become pregnant every year in
North Carolina (7,227 in 2000)
and the great majority of them
become parents (5,415 in that
year). Since few of these very
young mothers marry or stay
in touch with their partner,
they look to trusted adults
both inside and outside the
family for assistance. Health
providers are one such
group of adults; DSS staff
is another.
A DSS can help girls
and families negotiate the
legal complexities of dif-ficult
circumstances.
Legal issues the agency
may become involved in
include the following.
• Can parents put a pregnant minor child
out of their home?
• What are a pregnant or parenting ado-lescent’s
rights to attend school or com-munity
college or, for that matter, to
work?
• Are teens responsible for their child’s
support? If not, who is?
• Does a foster child who becomes a
mother have a right to have her child
with her in foster care? If so, can she
take the child when she leaves at age 18?
• Can a DSS with custody of a minor who
is a mother and of her child fairly repre-sent
both?
A book on the legal aspects of adolescent
health care during pregnancy (Health Care
for Pregnant Adolescents: A Legal Guide) was
discussed here recently (Forum, #3, 2001)
and sent to approximately 8,000 health
providers, thanks to grants from the Z.
Smith Reynolds Foundation and the School
of Government, UNC, Chapel Hill. (The
health providers’ book can be printed from
www.adolescentpregnancy.unc.edu or pur-chased
from the Institute of Government,
919.966-4119.)
Now, a second volume, Social Services for
Pregnant and Parenting Adolescents: A Legal
Guide, has been published. Some physicians
may want this guide as well to help them
advise patients and their parents. Although
the book is primarily for DSS employees and
other social workers, a limited number of
copies is available without charge for physi-cians.
(To request a copy, e-mail Anne
Dellinger, dellinger@iogmail.iog.unc.edu, and
include a mailing address.) The
second guide may
also be printed
from the Web site
above.
The story that
opens this article is
typical in that even a
pregnant or parenting
girl who is mature,
bright, and competent
for her age probably
lacks some of the
resources needed now or
for the future: sufficient
income and education,
housing, transportation,
health insurance, employ-ment,
child care, and child
support among others. In
addition, as a minor she
lacks the ability under law to control most—
though not all—of her decisions. For these
clients, as well as for their parents and chil-dren,
a DSS is a crucial resource.
Under state law, a DSS may be called on
to protect a minor from abuse, neglect, or
dependency; to pass along to law enforce-ment
information about statutory rape,
domestic violence, or other crimes that may
have physically harmed a minor; perhaps to
act as a minor’s custodian, consenting to her
medical care in some instances or other
important matters; to seek termination of
her parents’ rights or of her own rights as a
parent; to find a home for her and perhaps a
child; or to help her place a child for adop-tion.
For minors who need less support,
DSS may still be the gateway to essential ser-vices
such as cash assistance, child support,
day care, Medicaid, or the food supplements
of the WIC program. Another possibility is
that a DSS will encounter a minor solely as
a parent when it undertakes for her child
some of the obligations mentioned above.
Federal law, too, requires that a DSS work
with unmarried pregnant teens and preteens
Social Services for Pregnant and Parenting Adolescents
Anne Dellinger, JD
Professor, Public Law and Government, Institute of Government
The University of North Carolina at Chapel Hil
This commentary continues Professor
Dellinger’s presentation of titles in the new
series on pregnant and parenting adolescents
being published by the Institute of
Government, the University of North
Carolina at Chapel Hill.
Professor Dellinger has been a faculty
member at the Institute since 1974. She
was formerly of counsel with Hogan &
Hartson, Washington, DC, and is author of
numerous publications on health and hospi-tal
law, including an article, How We Die in
North Carolina, in Forum #2, 1999. Her
article on the first volume in the Legal
Guide Series appeared in Forum #3, 2001.
Summer before
last, in early
August, a health
department nurse
asked what could
be done for one of
her patients, a 17-
year-old in late
pregnancy. The
nurse’s concerns
were not medical;
the young woman
had been keeping her appointments and was
healthy. Still, her problems were serious.
Months earlier, on discovering the pregnan-cy,
her mother had told the girl to leave, and
the patient made her way to a stepfather in
North Carolina. Here, she became semi-homeless.
That is, some nights the stepfa-ther
let her stay with him, but otherwise she
had difficulty finding a bed. The girl’s great-est
concern was
school. She had
been a very good
student, wanted
to do her senior
year here, and
hoped for a col-lege
scholarship.
However, the
local high school’s
registrar would
only enroll her if
the stepfather
came to school
between 8 AM and
noon on a weekday. He was a construction
worker and unwilling or unable to lose a
day’s pay to do it.
The nurse was advised to call the local
department of social services (DSS) and also
to talk with a school attorney at the Institute
“Thousands of
girls 17 or younger
become pregnant
every year in
North Carolina
(7,227 in 2000)
and the great
majority of them
become parents
(5,415 in that
year)”
No. 3 2002 17
Professor Dellinger
Social Services
continued from page 17
in numerous specific ways.
Like Health Care for Pregnant Adolescents,
the DSS book reviews the legal and medical
requirement to explain pregnancy options to
a patient so she can decide to continue or
end the pregnancy. It also describes the law
of emancipation, marriage for minors, the
process the General Assembly recently estab-lished
for surrendering a newborn, and basic
information for parents who are considering
placing a child for adoption. The guide
emphasizes DSS’s general legal responsibili-ties
to minor clients: protection, informa-tion,
advocacy, impartiality, and confidential-ity.
It contains sections on domestic violence
in adolescent relationships, on DSS direc-tors’
and employees’ personal liability, and
much broader coverage of parenting issues
than the health providers’ book. Possible liv-ing
arrangements for minors are discussed,
along with parents’ rights and duties, termi-nation
of parental rights, and how—and
why—a single mother should establish her
child’s paternity, seek to have the child legit-imated,
and obtain a child support order. As
a companion to the book, a resource list for
social services is posted on the Web site,
www.adolescentpregnancy.unc.edu.
Nota Bene
About the Legal Guide Series
Health Care for Pregnant Adolescents: A Legal Guide was published by the Institute of Government,
the University of North Carolina at Chapel Hill, in fall 2001. The second title in the series, Social
Services for Pregnant and Parenting Adolescents: A Legal Guide (discussed in the previous article), is
now available. A third guide will follow for public school employees; a fourth for parents of preg-nant
and parenting teens and preteens; and a fifth for adolescents themselves. Each will be
announced in the Forum when it is available.
Comments on Social Services for Pregnant and Parenting Adolescents:
A Legal Guide
“This handbook. . .is an impressive piece of work and I think will be very useful to county staff in
offering support to this population. Dellinger has done her research well.”
—David Atkinson, Division of Social Services, NC Department of Health and
Human Services
“I really like the tone. It’s clear and readable without telling busy caseworkers more than they need
to know.” —Gretchen Aylsworth, District Administrator, Guardian Ad Litem Program
“This document is wonderfully ‘pithy’—full of terrific info. I can only imagine the time and focus it
took!”
—Beth Brandes, Associate Director, Catawba County Department of Social
Services
“This is a great resource—easy to follow, informative, and non-judgmental.”
—Sharon Holmes, University of North Carolina at Chapel Hill School of Social
Work, former Director, Orange County Adolescent Parenting Program
“You have done an outstanding job with this and it will be an invaluable resource.”
—Tyrone Wade, Associate County Attorney/Mecklenburg
“No one had any comments except positive ones. We all found the guide to be very readable, clear,
concise, with information well organized. We can see where this manual will be a valuable tool for
us, as a supplement to policy and procedures already in place.”
—Sandra Wilkes, Director of Social Services, Rowan County
Each employer has a responsibility to
ensure that those licensed persons in their
employ are appropriately credentialed. One
should never accept just a presentation of the
wallet-sized card as validation of the person’s
licensure status. To validate that a nurse
holds a current license to practice in North
Carolina, call (919)-881-2272 or access our
Web site at www.ncbon.com and click on
“Verify License.” You will need the individ-ual’s
Social Security number or North
Carolina nursing certificate number to access
this system. If you are unable to verify the
license through one of these applications
(telephone verification or Web-based verifi-cation),
immediately call the Board of
Nursing for clarification at (919) 782-3211.
In addition, under North Carolina
General Statute 90-640, any health care
practitioner who is licensed, certified, or reg-istered
to engage in the practice of medicine,
nursing, or other health profession must
wear a badge or otherwise display in a read-ily
visible manner that person’s name and
licensure, certification, or registration title
when providing care to patients.
This year, the North Carolina Board of
Nursing has received an alarming increase in
the number of complaints related to persons
who represent themselves to the public as
licensed nurses when they do not hold, nor
have they ever held, a license to practice
nursing in North Carolina. These individu-als
have ranged from individuals working in
office-based practices who call themselves
“office nurse” to imposters who create and
present fraudulent documents indicating
they are licensed nurses.
North Carolina General Statute 90-
171.43 states: “No person shall practice or
offer to practice as a registered nurse or
licensed practical nurse, or use the word
‘nurse’ as a title for herself or himself, or use
an abbreviation to indicate that the person is
a registered nurse or licensed practical nurse,
unless the person is currently licensed as a
registered nurse or licensed practical nurse as
provided by this Article.” To practice nurs-ing
without holding a license is a violation of
the Nursing Practice Act; a misdemeanor in
North Carolina.
Just recently it came to the Board of
Nursing’s attention that an individual had
been employed in an office-based practice
for nine years as the “Chemotherapy Nurse”
even though this person had never been
licensed to practice as a nurse. Other indi-viduals
working in office-based practices
who represented themselves as nurses, but
did not hold, nor had they ever held, a
license to practice nursing have been report-ed
to the Board by consumers who are con-cerned
about the safety of care they receive.
The Board of Nursing requests your
support in helping protect the public by
ensuring that only appropriately licensed
individuals use the term “nurse” and that all
name badges include the proper licensure
credentials. Please confirm current licensure
by utilizing our automated verification
system as noted above. The public needs to
be assured that their health care providers
are properly licensed and wear name badges
that accurately present them to the public
they serve.
From The Board Of Nursing
The Importance of Verifying the Licensure Status of Nurses
Employed in Office-Based Practices
18 NCMB Forum
As our third year of state budget crisis
drags on, we all are taking a careful look at
our personal and professional lives for frugal
remedies. A significant component of recent
growth in state expenditures has been the
Medicaid program. This program provides
needed services to the most vulnerable in our
community and is absolutely essential to pre-serving
health and preventing catastrophic
illness and wasteful crisis health care expen-diture.
A significant component of the increased
expenditure has been pharmaceutical sup-plies,
with over one billion dollars commit-ted
to this essential function during the past
year. The growth in this component of the
state budget has been far greater than any
projections, partly due to the introduction of
new drugs and exciting new therapies.
These new therapies, however, often come
with a high price tag. The 2001 cost is stag-gering:
Celebrex® $21 million, Prilosec® $39
million, Oxycontin® $15 million, and Vioxx®
$15 million, to name a few. On the horizon
are exciting but costly new drugs, among
them recombinant growth hormone
(Serostim®) for AIDS wasting syndrome for
a mere $6 thousand per month per script.
Did we really consider older and established
agents before prescribing all that Celebrex®?
Use of generic drugs can produce enormous
savings. A 30-pill bottle of generic atenolol
costs $6.99 compared to brand name
Tenormin® at $36.57. Are 30 pills of
Zocor® at $66.94 really that much better
than generic lovastatin at $36?
These examples of high cost items are har-bingers
for some of the challenges we will
face as new drugs become available over the
near future. No one wishes to balance our
state budget on the backs of the most vul-nerable
in our society but there is room for
From NCDHHS Division of Medical Assistance
As Stewards of the Medicaid Budget, We Can Do Better!
David H. Gremillion, MD, FACP
N.C. Medicaid DUR Board Member
President, Wake County Medical Society
Dr Gremillion
improvement in our fiscal management of
this precious pharmaceutical resource. Any
physician with practice experience recog-nizes
that although the new agents with
fancy attributes and the glossy promotional
brochures are exciting, they are also costly
and relatively unknown in the post market-ing
or practice environment. How well we
remember such examples as Omnifloxin®,
which was released to great fanfare only to
be removed from the market precipitously
eight weeks later with unanticipated hemol-ysis.
Our experience tells us that some of the
tried and true agents are not only equal to
the newly released products but superior in
many ways since the toxic profiles, side
effects, and prescribing nuances are well
known. These agents often provide equal or
even superior therapeutic benefit at dramat-ically
reduced cost. As physicians, we are in
the unique position to have an immediate
impact on the state Medicaid budget by con-scientiously
and thoughtfully prescribing
medications that are needed, but with a care-ful
awareness of the cost issues.
W. Pories
etc etc etc
2001 Medicaid Pharmacy Costs
Approximately one-sixth of the expenditures
for the entire Medicaid program in North
Carolina were for pharmaceutical drugs.
Eleven classes of drugs accounted for over
50% of that cost. The top six drug classes
and expenditures are cited below.
1. Gastric Acid Secretion Reducers:
$97,817,941 for 9.7% of total
expenditures
2. Anti-Psychotics (atypical, dopamine,
and serotonin):
$83,599,968 for 8.3% of total
expenditures
3. Anticonvulsants:
$50,019,568 for 4.97% of total
expenditures
4. Selective Serotonin Reuptake
Inhibitors:
$47,972,910 for 4.77% of total
expenditures
5. Analgesics/Narcotics:
$45,344,908 for 4.5% of total
expenditures
6. NSAIDS/COX Inhibitors:
$44,877,835 for 3.5%
of total expenditures
No. 3 2002 19
Risk Management - 2002
20 NCMB Forum
Annulment:
Retrospective and prospective cancellation of the
authorization to practice.
Conditions:
A term used for this report to indicate restrictions
or requirements placed on the licensee/license.
Consent Order:
An order of the Board and an agreement between
the Board and the practitioner regarding the
annulment, revocation, or suspension of the
authorization to practice or the conditions and/or
limitations placed on the authorization to practice.
(A method for resolving disputes through infor-mal
procedures.)
Denial:
Final decision denying an application for practice
authorization or a motion/request for reconsider-ation/
modification of a previous Board action.
NA:
Information not available.
NCPHP:
North Carolina Physicians Health Program.
RTL:
Resident Training License.
Revocation:
Cancellation of the authorization to practice.
Summary Suspension:
Immediate temporary withdrawal of the autho-rization
to practice pending prompt commence-ment
and determination of further proceedings.
(Ordered when the Board finds the public health,
safety, or welfare requires emergency action.)
Suspension:
Temporary withdrawal of the authorization to
practice.
Temporary/Dated License:
License to practice medicine for a specific period
of time. Often accompanied by conditions con-tained
in a Consent Order. May be issued as an
element of a Board or Consent Order or subse-quent
to the expiration of a previously issued tem-porary
license.
Voluntary Dismissal:
Board action dismissing a contested case.
Voluntary Surrender:
The practitioner’s relinquishing of the authoriza-tion
to practice pending an investigation or in lieu
of disciplinary action.
NORTH CAROLINA MEDICAL BOARD
Board Orders/Consent Orders/Other Board Actions
May - July 2002
DEFINITIONS
ANNULMENTS
NONE
REVOCATIONS
NONE
SUSPENSIONS
TALLEY, Joseph Harold, MD
Location: Grover, NC (Cleveland Co)
DOB: 4/20/1937
License #: 0000-15270
Specialty: FP (as reported by physician)
Medical Ed: University of Virginia (1963)
Cause: Following a hearing on March 21-23, 2002, the Board found
Dr Talley failed to perform adequate physical or objective
examinations in order to evaluate or diagnose patients’ com-plaints,
that he failed to perform follow-up physical examina-tions
to rule out or confirm the causes of pain prior to insti-tuting
or continuing opioid therapy, that he failed to inquire if
his patient has received medications from other physicians or
sources when he knew or had reason to believe the patient had
a history of abusing drugs, that he failed to monitor patient
compliance with the prescribed thera

Click tabs to swap between content that is broken into logical sections.

Primum Non Nocere
N C M E D I C A L B O A R D
In This Issue of the FORUM
President’s Message:
Lessons from a Crow.....................................1
From the Executive Director:
Our Ecosystem .............................................1
Fondly, Carolyn:
Letters to a Young Physician .........................4
Dr Collman Named Part-Time Medical
Coordinator for NCMB .............................6
NCMB Elects Officers ...................................7
The Intersection of Public Health and
Pharmacy for Older Adults: Making
Sure That “Doctors’ Orders”
Can and Should Be Followed.....................8
Dr Dees Honored by Duke University
Medical Center.........................................11
NCMB Revises Two Position Statements .....11
President’s
Message
Walter J. Pories, MD
Primum Non Nocere
NORTH CAROLINA
MEDICAL BOARD
April 15, 1859
Item Page Item Page
Lessons from a Crow
They made a big deal about those two
birds. Apparently Betty and her mate were
the subjects of a test to determine whether
crows could learn how to extract meat from
a test tube with a wire. The birds were pre-sented
with two wires, one straight and the
other bent into a hook. The experiment did
not last long. As soon as the crows learned
that only the bent wire was effective, the
dominant male commandeered the tool.
Betty’s response was to bend the remaining
wire by wedging it into a crack in the cage,
adjusting it until she had a functional tool.
The folks at Oxford University are normally
quite reserved, but they were excited this
time. The observation proved that birds not
only use tools but also can fabricate them. I
didn’t think it was such a big breakthrough
because, at least on our farm, we have all
sorts of livestock who keep outsmarting us.
The more interesting aspects to the story
are that 1) Betty learned when and what she
needed to know, 2) she improved with prac-tice,
3) and her learning was measured by
outcomes.
These basic principles of education, even
applicable to crows, differ from our
approach to the continuing education of
physicians. Currently, we simply mandate
the process. In North Carolina, physicians
must document 150 hours of practice rele-vant
CME every three years in order to stay
up to date.
b) Each person licensed to practice
medicine in the State of North
Carolina shall complete no less
than 150 hours of practice relevant
CME every three years in order to
enhance current medical compe-tence,
performance or patient care
outcome. At least 60 hours shall
be in the educational provider-ini-tiated
category as defined in Rule
.0102 of this Section. The remain-ing
hours, if any, shall be in the
physician-initiated category as
Our Ecosystem
To use an analogy with nature, a medical
board is in a complex community of organi-zations
instead of organisms. This commu-nity
has a more profound impact on public
protection and the profession of medicine
than many may think. When we go out to
speak to various community groups, people
are often surprised to learn the breadth and
scope of this Board’s activities. For
licensees, unless they have been on the
receiving end of complaints or investiga-tions,
their last contact with the Board may
have been many years ago in the context of
applying for a license. This is, perhaps, not
typically viewed as a pleasurable experience
and is, thus, easy to use as a basis for formu-lating
opinions about the Board. If one
reads this Forum, of course, one gets a broad-er
understanding. To really gain insight into
the process, it would be worthwhile to
explore some of the organizations with
which we relate.
Federation of State Medical Boards
The most important, of course, is the
Federation of State Medical Boards of the
United States (FSMB). Founded in 1912,
this is an organization of all the medical
boards in the United States. It has also
extended affiliate membership to similar
licensing authorities in several other coun-tries.
The Canadian provinces and the
Federation of Medical Licensing Authorities
of Canada hold affiliate membership. The
FSMB is based in Euless, Texas, near Fort
Worth. Its mission is continual improve-ment
in the quality, safety, and integrity of
health care through the development and
promotion of high standards for physician
licensure and practice. The most valuable
continued on page 3
continued on page 2
Is Your Attitude Getting in Your Way? .........12
Physician Behavior .......................................14
Social Services for Pregnant and
Parenting Adolescents ..............................17
The Importance of Verifying the
Licensure Status of Nurses Employed
in Office-Based Practices ..........................18
As Stewards of the Medicaid Budget,
We Can Do Better! ..................................19
etc etc etc .....................................................19
Board Actions: 5/2002-7/2002 ...................20
Board Calendar ............................................24
Change of Address Form .............................24
No. 3, 2002 forumFondly, Carolyn: Letters to a
Young Physician, Part III - page 4
From the
Executive
Director
Andrew W. Watry
The Forum of the North Carolina Medical Board is published four times a year. Articles appearing in the Forum,
including letters and reviews, represent the opinions of the authors and do not necessarily reflect the views of the
North Carolina Medical Board, its members or staff, or the institutions or organizations with which the authors are
affiliated. Official statements, policies, positions, or reports of the Board are clearly identified.
We welcome letters to the editor addressing topics covered in the Forum. They will be published in edited form
depending on available space. A letter should include the writer’s full name, address, and telephone number.
North Carolina Medical Board
Raleigh, NC forum N C M E D I C A L B O A R D
Vol. VII, No. 3, 2002
Primum NonNocere
NORTH CAROLINA
MEDICAL BOARD
April15, 1859
Primum Non Nocere
2 NCMB Forum
Walter J. Pories, MD
President
Greenville
Term expires
October 31, 2003
John T. Dees, MD
Vice President
Bald Head Island
Term expires
October 31, 2003
Charles L. Garrett, Jr, MD
Secretary-Treasurer
Jacksonville
Term expires
October 31, 2002
George C. Barrett, MD
Charlotte
Term expires
October 31, 2002
E.K. Fretwell, Jr, PhD
Charlotte
Term expires
October 31, 2002
Hari Gupta
Morrisville
Term expires
October 31, 2004
Stephen M. Herring, MD
Fayetteville
Term expires
October 31, 2004
Robin N. Hunter-Buskey, PA-C
Gastonia
Term expires
October 31, 2003
Elizabeth P. Kanof, MD
Raleigh
Term expires
October 31, 2002
Robert C. Moffatt, MD
Asheville
Term expires
October 31, 2004
Michael E. Norins, MD
Greensboro
Term expires
October 31, 2004
Aloysius P. Walsh
Greensboro
Term expires
October 31, 2003
Andrew W. Watry
Executive Director
Bryant D. Paris, Jr
Executive Director Emeritus
Publisher
NC Medical Board
Editor
Dale G Breaden
Assistant Editor
Shannon L. Kingston
Address
1201 Front Street, Suite 100
Raleigh, NC 27609
Telephone
(919) 326-1100
(800) 253-9653
Fax
(919) 326-1130
Web Site:
www.ncmedboard.org
E-Mail:
info@ncmedboard.org
Lessons from a Crow
continued from page 1
defined in Rule .0102 of this
Section.
The rule misses the mark. Can we assess
a baker by the number of hours he spent
reading a cookbook? Even so, it is certainly
not a demanding requirement. Attending
one meeting a year and reading about an
hour every two weeks fulfills the rules. Most
doctors do far more. They may read for
hours trying to find the right treatment for a
patient or to learn new health care rules.
The CME requirement arose out of a con-cern
that doctors would not continue to
learn once they were out of residency. As if
doctors are not eager to learn! The facts
show just the opposite. Think of how rapid-ly
laparoscopy spread across the U.S. as sur-geons
attended courses by the thousands, at
significant personal expense, to learn this
new technology. Similarly, consider the
speed by which other advances crossed the
U.S., such as the insertion of cardiac stents,
endovascular surgery, new chemotherapeutic
agents, and management of arrhythmias. In
fact, the prescription of some drugs spreads
so quickly that third-party payers have to
conduct sessions to prevent their introduc-tion.
There is ample evidence that physi-cians
do not have to be forced to learn.
Bill Gates recently said that more discov-eries
were made in the last decade than in the
rest of recorded time. President Clinton put
it a little differently with his statement that
science doubles every six years. Either way,
it suggests that a 50-year-old physician, who
graduated at the age of 26, had to learn 75
percent of his current fund of knowledge
since he finished medical school. Further,
before he retires, he will need to expand his
knowledge by another 300 percent.
Fortunately, we now have better
approaches to learning than textbooks that
are often out of date by the time they are
published, erratic journal articles, and lec-tures
in far-away-places. The advent of the
Internet, the availability of inexpensive com-puter
memory, and the widespread familiari-ty
of physicians with computers allow us to
think outside the box. It is now possible to
provide full courses over the Internet based
on curricula that are stratified to meet the
needs of the individual. These courses could
be presented in modules so they can be
learned or reviewed in manageable seg-ments.
Further, it is now feasible to include
a test at the end of the course that is graded
independently to help the learner evaluate
progress.
Many of our medical schools have most of
the educational materials required for such a
venture. We could review the strengths of
each institution and, based on this survey,
assign each institution segments of a nation-al
Internet curriculum. For example, the
Johns Hopkins might be asked to provide a
full teaching module covering the diseases of
the pancreas, while the Rockefeller Institute
might be assigned the course on genetics.
With this approach, we could have a living
text that is always up to date, with a pro-gram
that would be available at any time and
wherever there is a telephone and computer.
Further, successful completion of the test in
the module could also provide documenta-tion
of learning.
Such an initiative in continuing education
would be, I think, an advance over our cur-rent
approach. It might almost catch us up
with the methods used for Betty, the crow.
_____________________
Photo of Betty the Crow reprinted with permis-sion
from Shaping of Hooks in New Caledonian
Crows by Weir, et al, Science 297, 981 (2002) fig
1. Copyright 2002, American Association for the
Advancement of Science.
E-Mail:
info@ncmedboard.org
Web Site:
www.ncmedboard.org
North Carolina
Medical Board
Betty at Work
No. 3 2002 3
Our Ecosystem
continued from page 1
aspect of the FSMB to us is its membership.
Through this organization, we interact quite
regularly with the larger community of med-ical
boards. The primary vehicle for this is
an annual meeting held in April. We serve
on various FSMB committees, and the year
before last the elected president of the FSMB
was one of our Board Members, George C.
Barrett, MD. This organization is far and
away the most influential national organiza-tion
to coordinate licensure standards
among the states. Beyond this, it adminis-ters
the uniform physician licensing exami-nation
(the United States Medical Licensing
Examination) and provides other valuable
services. A brief sample follows.
Examination Services: In cooperation with
the National Board of Medical Examiners,
the FSMB created and administered the first
uniform licensing examination, known as
the Federation Licensing Exam (FLEX),
which was adopted by all but one of the
states. This was the precursor to the pre-sent-
day United States Medical Licensing
Examination (USMLE), the three steps of
which were introduced between 1992 and
1994. This is one of the finest examinations
in the examination marketplace, setting the
benchmark for psychometric standards. The
USMLE very effectively tests graduates of
both U.S. and foreign medical schools for
knowledge, skills, and abilities necessary to
safely practice medicine in the United States.
Additionally, there is an osteopathic exami-nation
administered by the National Board
of Osteopathic Medical Examiners.
Membership: In addition to 68 U.S.
boards (some states have separate medical
and osteopathic boards, and the boards of
the District of Columbia, Puerto Rico,
Guam, and the Virgin Islands are included),
the FSMB interrelates with many other key
players to be described later, including the
American Medical Association, the
Association of American Medical Colleges,
the American Osteopathic Association, the
National Board of Medical Examiners, the
Educational Commission for Foreign
Medical Graduates, the Accreditation
Council for Continuing Medical Education,
the National Commission on Certification
of Physician Assistants, and others.
Post-Licensure Assessment System: The
FSMB has developed a post-licensure assess-ment
system to deal with those who have
deficits in clinical skills and clinical perfor-mance
identified by medical boards. There
are essentially two components: (1) a special
purpose examination known as SPEX, and
(2) an assessment center that started out in
Colorado but now has evolved to test sites in
Texas and Philadelphia. This is a support
service for medical boards.
Credentials Verification Service (FCVS):
This is a service to greatly facilitate interstate
mobility of physicians by providing a central
repository of core medical credentials. This
is, therefore, a major service to medical
boards and the public served by these
boards. Having individual applications for
licensure in each state that require revalida-tion
of the same core credentials is redun-dant—
a holdover from years ago. The
FCVS provides a uniform, core-credential
verification system accepted in 47 states,
including ours, that provides an alternate
pathway for licensees who are highly mobile
from an interstate perspective. Six medical
boards require FCVS for licensure appli-cants.
It is particularly helpful to foreign
medical graduates who may have difficulty
obtaining core medical credentials each time
they move from state to state.
Other Activities: The FSMB maintains a
physician data center, collecting licensure
data from all states. It maintains a board
action data bank that receives disciplinary
data from the state boards in real time and
disperses it to other states immediately. This
limits a disciplined physician’s opportunity
to relocate or seek a license in another state
without that state knowing about his or her
disciplined status. Other FSMB activities
include educational offerings at annual meet-ings
and regional meetings, publications,
on-line resources, and the FSMB’s Web site
at www.fsmb.org. The FSMB also represents
medical board concerns before the Congress.
Here are examples of recent legislation mon-itored
at the Federal level: medical error leg-islation
(HR 4889 & 2590) and the Health
Care Safety Net Improvement Act (HR
3450). Each year, there are more and more
pieces of proposed legislation at the
Congressional level that impact licensing
boards. Also, the FSMB monitors legislative
trends within the states and feeds this infor-mation
back to the membership.
Education Commission for Foreign
Medical Graduates (ECFMG)
The ECFMG began issuing certificates in
1958. Its principal customers at that time
were post-graduate training programs in the
United States that were accepting graduates
of foreign medical schools. It provided a
basis for uniform credentialing of foreign
medical graduates through a process with
three elements: an English competency
examination; a basic medical competency
examination; and a credentials check. The
ECFMG process has steadily evolved, elimi-nating
redundancies and enhancing public
protection. The medical competency por-tion
of its certification process is now a part
of the USMLE, thus limiting redundancy. It
also requires clinical skills assessment involv-ing
standardized patients. This issue
addresses the disparity between training at
foreign medical schools and that in LCME
and AOA approved facilities, identifies com-munication
problems, and surfaces problems
that could not otherwise be detected
through multiple choice tests. It also admin-isters
a test of English as a foreign language.
National Board of Medical
Examiners (NBME)
The NBME has been in existence since
1915. It was founded by the FSMB, the
American Medical Association, and other
interested medical groups and has vast and
experienced psychometric resources for
examination development. It developed the
National Board of Medical Examiners exam-ination,
which was the precursor to the
USMLE for graduates of U.S. medical
schools. Graduates of foreign medical
schools did not have access to this examina-tion
and, therefore, principally took the
FLEX. The FLEX was developed in coop-eration
with the NBME. The examinations
were, therefore, quite similar and included
many examination items from the same item
pool. The uniform examination that finally
developed, the USMLE, eliminated any of
the minor discrepancies existing between the
two prior examination pathways. The
NBME also provides the expertise for other
testing instruments, including the SPEX,
mentioned earlier, and instruments in use for
clinical skills and post-licensure assessment.
Administrators in Medicine (AIM)
AIM is a national organization of medical
board executives formed in 1983. The pur-pose
of this organization is to develop and
achieve administrative excellence for medical
board executives. It augments but does not
compete with the services of the FSMB. Its
Web site is at www.docboard.org.
Conclusion
In conclusion, the North Carolina
Medical Board needs to work closely with
these other organizations in order to provide
optimal services to the citizens of this state.
In many cases, the Board has established a
track record of leadership in these national
organizations. The executive leadership of
the FSMB and the ECFMG is in the hands
of two former North Carolinians—James N.
Thompson, MD, and James A. Hallock,
MD, respectively. This is the second time
the FSMB’s executive leadership has been
connected to this state. Bryant L. Galusha,
MD, a Charlotte pediatrician and former
president of the North Carolina Medical
Board, was the FSMB’s executive vice presi-dent
from 1984 to 1989. Our support
of these organizations reflects continuing
commitment to the public mandate of the
Board.
4 NCMB Forum
continued on page 5
Fondly, Carolyn:
Take Time to Use Your Manners
Dear W:
Your “new” car sounds exciting and—
what shall I say—challenging! Are you sure
it was a good idea to buy a 15-year-old car
that was totaled? Well, I will hush now
because I know you know something about
cars and I don’t. Maybe it wasn’t totaled too
badly. I know it didn’t take much for the
insurance company to consider my last car
totaled because by that time the poor old
thing was barely rolling anyway! Shortly
before that, I had a flat tire on that car, and
the service station attendant took one look at
the car and at me and judged that we were
not worth being nice to. In fact, he was rude
and sarcastic. Three or four days later, I was
on my way home in the evening and got
paged to please come back to the hospital to
see a five-year-old girl with new-onset
seizures. Her parents were deeply scared by
what had happened to their daughter. As I
spoke with the mother and child, the father
faded into the shadows. I finally recognized
him as the service station attendant, and he
apologized for his previous discourtesy, say-ing:
“I’m so sorry, ma’am, I didn’t know you
were anybody who mattered.” After a
moment of internal conflict, grace prevailed
and I assured him all was forgiven and that
Carolyn E. Hart, MD
Dr Carolyn E. Hart, who practices neurology in
Charlotte, is president of the Mecklenburg County
Medical Society. In place of the usual president’s com-ments
in the Society’s publication, Mecklenburg
Medicine, she has prepared a series of letters to a med-ical
student, “W,” whose parents are physicians and
friends of hers. Her thoughts, so clearly and simply
expressed, unfold as a primer of sorts, laced with
insight and wisdom, a gentle and conversational guide
and reminder for health care professionals at any point
in their careers. We thank Dr Hart and
Mecklenburg Medicine for allowing us to present the
letters here. We will publish ten letters in all over this
year. Five were published in our first two numbers of
2002 and three more appear here to continue the
series.
Letters to a Young Physician
Part III
it would not affect my care for his daughter.
The characters’ roles in this true story could
very well have been reversed. The doctor
could have been rude to his/her patient’s
father, an uneducated man in greasy work
clothes, and then could have needed his help
with that flat tire. Either way, lack of cour-tesy
could cause a significant problem later.
It is therefore very important for physicians
to “Take Time to Use Your Manners.”
W, I know you are already a kind-hearted
and courteous young man, but when physi-cians
get busy and tired, even the gentlest
among us may sometimes neglect their man-ners.
We may snap
inappropriately at
our staff, patients,
family, and each
other. If this ever
happens, admit it!
As soon as you real-ize
you overreacted,
apologize sincerely,
even to your
preschool child or
your young front-desk
clerk. Remember your words have a lot
of power. Physicians are usually articulate,
strong-willed, and influential over the
health, happiness, and/or livelihood of those
around us. An encouraging word from you
could change someone’s life by supporting
their college plans or life change. On the
other hand, an unnecessarily sharp word
from you could reduce someone to tears and
he or she might never forget your harshness.
Remember, first do no harm.
The nurses and other staff in your hospital
and office deserve your courtesy and respect.
They often care and work as hard as you do,
and they too help patients through tough
times. They also will support your efforts
enthusiastically as they witness your polite-ness
and kindness toward your patients.
Conversely, your patients watch how you
behave toward your staff and may decide on
this basis whether or not to trust you with
their secrets and their lives. A friend of mine
walked out of her physician’s office and
switched physicians after hearing hers bark-ing
at a staff member. While wintering in
Florida, another friend needed complex
repeat angioplasty and decided to trust the
local cardiologist to do it after overhearing
the agreeable way in which he spoke with his
staff.
Our society now has some amazing tools
and toys, like cell phones, PDAs, and
portable CD/DVD players. W, you proba-bly
understand how these things work, but I
just use them, mindlessly enjoying their
magic. (I did buy a book called How Things
Work but haven’t yet found time to read it!)
The reason I mention these technical won-ders
is that they are new triggers for rude-ness
in daily life. When you are on your cell
phone in a public place, be sure to talk in a
normal voice or get a better phone. Don’t
drive and hold the phone to talk— pull over
or get an earpiece so both hands are on the
steering wheel. If someone is talking with
you, don’t bury your head in your PDA,
showing him the top of your head and not
your eyes. Don’t stay on the Internet during
family mealtimes or past bedtime. These
tools are fascinating, but people are even
more so.
Old-fashioned etiquette is important, too.
Look people in their eyes and shake their
hands when you meet them. Most staff and
patients already know you are a doctor, so
you usually don’t need to say “I’m Dr. G”;
just say “I’m WG.” You also don’t need to
put MD on your checks, license plate, or sta-tionery.
Let your staff and patients know at
least a little about yourself, but not too
much; it can be good to keep a distinction
between personal and professional parts of
your life. Ask about people’s lives and inter-ests,
make notes and ask again the next time
that you see them. Keep a collection of inex-pensive
congratulations and sympathy cards
to send your patients and others in grief or
in response to graduation and wedding
announcements. Except in crowded corri-dors,
nod or say “Good morning” or “Good
afternoon” to everyone you pass. Those
golden expressions, “please,” “thank you,”
“I’m sorry,” “would you,” and “could you
please,” are still very potent and almost
always get a positive result.
Remember what my service station atten-dant
learned and treat everybody as if they
were “somebody who mattered.” God,
through several of the religions of the world,
has given us the Golden Rule. He has also
set up our cellular aging processes such that
by midlife, our facial lines show a lot about
our personalities. My grandmother
explained it succinctly, saying: “At 40, you
get the face you deserve!” So, keep an eye
on the mirror over the next couple of
decades, W, to see if you are still remember-ing
to “Take Time to Use Your Manners”!
Good luck with that car!
Fondly,
Carolyn
“When physi-cians
get busy
and tired, even
the gentlest
among us may
sometimes
neglect their
manners”
No. 3 2002 5
continued on page 6
Fondly, Carolyn
continued from page 4
Take Time to Be Culturally
Competent
Dear W:
¿Que pasa? How was your trip to Mexico?
I hope you, your brother C, and your folks
had a great time. I have a feeling that may
be your last trip together as a family since
you and C have such busy schedules of your
own now. It was too bad B couldn’t join
you; I’m sure she missed you a lot. Did you
get to do any dancing? You know your
father, BG, is very good at the Texas Two-
Step, and he taught it to me. It somehow
reminded me of Cajun dancing and also of
clogging and polka. Isn’t it intriguing how
different cultures sometimes have such simi-lar
dance styles and, for that matter, music,
customs, and beliefs? You are such a curious
and enthusiastic young man, W, I know you
will enjoy exploring our world and learning
about other cultures. That will help make
you a better physician because it is very
important for physicians to “Take Time to
Be Culturally Competent.”
Striving to understand other cultures is
not only a compassionate and educational
exercise for physicians to undertake but is
becoming increasingly necessary to properly
care for our patients. Did you know that the
U.S. Census Bureau anticipates that in the
next five years 48 percent of U.S. residents
will be from cultures other than “white/non-
Hispanic”? By the year 2050, Hispanics are
expected to comprise 24.5 percent of the
U.S. population, and African Americans,
currently the largest minority, will constitute
15.4 percent of U.S. residents (Salimbene).
Other major minority groups include Asians
(currently about 3.4 percent), Middle
Easterners, American Indians, and emigrés
from former Soviet Bloc countries, especial-ly
Yugoslavia (Bosnia) and Poland. Within
each of these groups, there are subsets based
on age, gender, religion, sexuality, etc, and
the perspectives of these subsets and of indi-viduals
may differ from each other dramati-cally.
It is very important to learn about other
cultures, but not to make assumptions about
individual patients based on their nation or
culture of origin. This is the difference
between generalizing and stereotyping. It is
reasonable to use generalizations learned
about a culture or country in order to focus
on a patient’s potential beliefs or perspec-tives,
but not to stereotype the patient.
Often, it is helpful to ask the patient about
his/her foods, beliefs, family, and health
practices. A handbook about cultural differ-ences
can also be useful. The best that I have
found are What Language Does Your Patient
Hurt In? A Practical Guide to Culturally
Competent Patient Care, by Suzanne
Salimbene, PhD, (2000, ISBN
1883998247, 1-800-865-5549); and Pocket
Guide: Cultural Assessment, by Elaine
Geissler, PhD, (1999, 2nd Ed., ISBN
0815136331, www.us.elsevierhealth.com).
Both of these are excellent and describe
proper ways of addressing patients, touching
patients, collecting and conveying informa-tion,
reaching decisions, and understanding
differing con-cepts
of space,
time, and caus-es/
cures of ill-ness.
Although
these books are
enlightening, it
may be fun to
learn about other
cultures by expe-riencing
them
through travel
(perhaps a med-ical
work trip?),
music (Yo Yo Ma’s new CD, Silk Road
Journey, is a wonderful product of many cul-tural
influences), and food. I would also rec-ommend
listening to National Public Radio
and viewing the Public Broadcasting
System, exploring on the Internet (try
www.omhrc.gov and magma.national-geo-graphic.
com), and reading (try When I Was
Puerto Rican, by Esmeralda Santiago;
Monkey Bridge, by Lan Cao; The Spirit
Catches You and You Fall Down, by Anne
Fadiman; and Aman: Story of a Somali Girl,
by Virginia B. Lee). The best and most
enjoyable exploration method of all is to
simply chat with your patients, staff, and
neighbors from other cultures.
As our society has digested the news of
the 9/11/01 attacks and subsequent events,
some of our innocent Middle Eastern immi-grants,
sadly, have felt the backlash of our
shock. There have been some shameful
examples of stereotyping, though several
positive developments have also occurred. I
believe we have felt more patriotic gratitude
for daily freedoms, deeper respect for our
protectors, and a heightened awareness of
the rest of the world beyond our borders.
We have been jolted into a “frightened
eagerness to know about the ‘other’ world,”
according to Edward Brynn, director of
International Programs at UNC Charlotte,
in a recent interview with The Leader.
Charlotte now has international information
and support services (www.charlottemic.org/
resource.htm), and many Charlotteans are
learning or reviewing Spanish or other lan-guages,
demonstrating a welcoming attitude
toward these newcomers. I mentioned a
couple of months ago that I have been learn-ing
Spanish by listening to tapes and using a
CD-ROM program, but my young patients
have been my best instructors. At each visit,
I ask them to teach me to say something in
their language.
W, you are a lucky fellow to be bilingual
and to have such familiarity with the
Hispanic immigrants and American Indian
communities near your Southwest home.
Having grown up in an integrated mountain
community in South Carolina, I thought I
was similarly familiar with African-American
culture but have come to realize that there is
remarkable diversity among African-
Americans’ beliefs, backgrounds, and prac-tices.
Although most African-Americans
help define “mainstream” American culture,
others are of very different and unfamiliar
backgrounds.
Many ethnic groups have traditional or
folk healing methods that may be helpful,
neutral, or harmful. I remember that you
and your mother, L, have worked with some
of the American Indians in New Mexico and
Arizona. Did you have any chance to learn
of their folk healing methods?
W, I am sorry this letter is a little longer
than most, but cultural diversity is one of my
favorite topics. You have a cheerful and
inquisitive nature, and I know you will con-sider
the project of learning about other cul-tures,
not as a physician’s obligation to his or
her patients, but as a fun, lifelong explo-ration
of the amazing mosaic of our world.
Remember to “Take Time to Be Culturally
Competent” and have fun doing so! Hasta
la proxima mes!
Fondly,
Carolyn
Take Time to Live Healthily
Dear W:
I’m sorry to hear that you got mycoplas-ma,
and I hope you are starting to feel better
now. I had mycoplasma once during resi-dency
and remember that uncontrollable
cough. The doctor at the employee health
center paged me and asked me how much I
smoked because the chest X-ray showed a
large tumor with several lytic bone lesions.
This was not an optimal way to hear such
scary news, and your mom was very sup-portive.
Since I’m still here to tell the story,
you know the ending was happy (for me). I
never smoked, and the names on the chest X-rays
had just gotten mixed up! On the pos-itive
side, that experience helped me focus
“Striving to under-stand
other cul-tures
is not only a
compassionate and
educational exer-cise
for physicians
to undertake but is
becoming increas-ingly
necessary”
6 NCMB Forum
on how to live fully and provided me with a
great example of how not to convey bad
news to a patient!
As you start feeling better, W, don’t forget
to finish all your doses! You know doctors
are not known for being very good patients!
Surely between B and your folks, you will be
coerced into taking your meds and also rest-ing
properly!
This month is the anniversary of the
vicious 9/11/01 attacks, and we are all still
bruised. I can’t tell you how many kids I
have seen this year with increased headaches,
sleep problems, and other signs of stress.
Many doctors have spent a lot of time since
last September trying to comfort our
patients, and I thought perhaps it was time
to write about how we must take care of
ourselves as well. To be a good physician,
W, you will need to “Take Time to Live
Healthily.”
JA, a local obstetrician, says that five
things are required for a healthy and happy
life: trust in a higher power, a calling, a lov-ing
relationship with another adult, an avo-cation,
and exercise. In order to live health-ily,
a physician must look after his/her mind,
body, and spirit. W, you seem to me to be
faring well in all three spheres, but it is easy
to get “out of shape” in any of them. It is a
healthy exercise to take an inventory of each
area occasionally, recognizing your strengths
and acknowledging your weaknesses. Both
were conferred on us by a higher power, and
together they make us the special but quirky
individuals we are.
Physicians tend to have fairly healthy
minds, learning easily and often delighting
in mental challenges. Nevertheless, we often
have ADHD, learning disabilities, or other
imperfections that cause frustrations in our
daily lives and inconsistencies in our perfor-mance
patterns. Contrary to popular belief,
these conditions can occur in bright, accom-plished
adults (see www.chadd.org and
www.ldanatl.org). People with an undiag-nosed
neuropsychiatric condition sometimes
resort to self-medicating with alcohol or
other substances, often leading to more seri-ous
problems. Substance abuse causes huge
problems in our world, and physicians and
our families are certainly not immune. In
fact, we may be more vulnerable than aver-age
in this area, perhaps due to our pressured
schedules, independence, and reluctance to
seek help, especially for problems of the
mind or spirit. There is a lot of good help
available though, especially through
Alcoholics Anonymous (www.aa.org), the
Fondly, Carolyn
continued from page 5
North Carolina Medical Board (www.ncmed
board.org/php.htm), and Al-Anon (www.al-anon
.alateen.org). W, if you ever experience prob-lems
like this, get help! Don’t self-medicate!
W, I have never been quite sure how to
divide mind and spirit since the fields that
study them seem to overlap and since it is all
about the brain! OK, OK, I might be a lit-tle
biased! Somehow spiritual health is more
abstract, though, and is the source of happi-ness,
love, serenity, and everything else for
which I cannot describe a neural circuit!
Just as problems with attention or learning
can affect your mental health, difficulties
with anxiety, depression, anger, and lack of
trust in a higher power can damage your
relationships, self-esteem, and overall spiri-tual
health. While preparing to write you
this letter, I asked several friends for advice
on ideas that could
guide one’s life. Try
asking your friends
this; the answers are
beautiful. The answers
I received included:
“The Lord’s Prayer”;
Frost’s “The Road Not
Taken”; “Might as well
do it right”; “Slow
down, Doc, tomorrow
ain’t promised to none of us” (an employee);
“The Serenity Prayer” (www.open-mind.
org/serenity); and my own favorite,
“Desiderata” (Max Ehrmann, 1927; try
desiderata as a search word). W, I hope you
will always remain humble enough to accept
advice from your family and friends and to
seek help if you need it!
The importance of physical health seems
apparent to physicians, and yet ironically we
often neglect our own bodily health. Many
of us delay checkups and push ourselves
through long workdays, leaving little time
for relaxation, conversation, careful nutri-tion,
sleep, and exercise. Although we sleep
less (averaging about 6.5 hours) than our
predecessors (8.2 hours) a few decades ago,
at least we also smoke less, too! In an unpre-tentious
Italian restaurant in Charlotte, there
is a framed magazine advertisement pictur-ing
a Rockwellian physician and his patient
and proclaiming “More Doctors Smoke
Camels!” Let’s hope not! We have certain-ly
made progress in understanding risk fac-tors
and publicizing healthy standards
(www.health.discovery.com and www.time.com/
time/health), but we still need to remember
to eat right, sleep enough, and exercise. Live
like your grandmother is watching and “Go
outside and get some fresh air!”
Although Epicurus’ name has been mis-takenly
associated with pleasure and privi-lege
(see Epicurean magazine, www.epicurean
.com), he actually espoused a philosophy of
life very similar to JA’s recommendations for
health and happiness. Epicurus recom-mended
basic foods, shelter, and simple
clothing, but most importantly, friends and
freedom of thought. More recently, Mary
Chapin Carpenter’s song “Passionate Kisses”
provides a similar wish list for achieving
health and happiness (see www.geocities.
com/islandlyrics).
W, I hope you feel better soon! I have to
go now and call for an appointment for my
checkup!
Fondly,
Carolyn
“In order to
live healthily,
a physician
must look after
his/her mind,
body, and spir-it”
Dr Collman Named
Part-Time Medical
Coordinator for
NCMB
Andrew W. Watry, executive director
of the North Carolina Medical Board, is
pleased to announce the selection of
Mitchell S. Collman, MD, FACC, as a
part-time medical coordinator for the
Board. He joins Gary M. Townsend,
MD, JD, who came to the Board as its
full-time medical coordinator in the sum-mer
of 2000. Dr Collman is board-certi-fied
in both internal medicine and cardi-ology
and is actively practicing as a cardi-ologist
in the Raleigh area. He serves as
a clinical assistant professor in the
Cardiology Division of the University of
North Carolina School of Medicine.
A native of New York, Dr Collman
received his BS from Rensselaer
Polytechnic Institute and his MD degree
from Albany Medical College in their
combined six-year program. He then did
his internal medicine training at the
University of Michigan Medical School
and his cardiology fellowship at the
University of North Carolina.
Dr Collman also has experience as an
emergency medicine physician and acts as
a consultant for the Social Security
Administration and Medical Review of
North Carolina. He is a fellow of the
American College of Cardiology and a
member of the Wake County and North
Carolina Medical Societies.
Dr Collman will serve as an advisor to
the Board staff in areas requiring medical
expertise and facilitate the Board’s evalua-tion
of the increased volume of com-plaints,
malpractice reports, and other
matters involving issues of medical care in
North Carolina.
No. 3 2002 7
continued on page 8
Andrew W. Watry, executive director of
the North Carolina Medical Board, has
announced the Board’s election of its officers
for the coming year: John T. Dees, MD, of
Bald Head Island, president; Charles L.
Garrett, Jr, MD, of Jacksonville, president
elect; Mr Hari Gupta, of Morrisville, trea-surer;
and Stephen M. Herring, MD, of
Fayetteville, secretary. They take office on
November 1, 2002 and will serve until
October 31, 2003. (Note that the position
of vice president of the Board is eliminated
as of November 1, 2002. It is replaced by
the newly created office of president elect.)
John T. Dees, MD, President
John T. Dees, MD, of Bald Head Island
(formerly of Cary), becomes the Board’s
president on November 1, 2002, replacing
Dr Walter Pories, of
Greenville, in that
position. A family
physician, he practiced
for many years in his
native Burgaw, a rural
area of the state. He
received his under-graduate
education at
the University of
North Carolina,
Chapel Hill, and his
MD from Duke University School of
Medicine. He did his internship at
Durham’s Watts Hospital and his residency
at Duke Hospital. He is a charter diplomate
of the American Board of Family Physicians.
Besides his private practice, Dr Dees has
served, among other things, as Pender
County Health Director, chief of staff of
Pender Memorial Hospital, and medical
director of the Huntington Health Care
Center. He has rendered distinguished ser-vice
to a wide variety of professional organi-zations,
including the North Carolina
Academy of Family Physicians, the North
Carolina Medical Society, the American
Academy of Family Physicians, the Southern
Medical Association, the Wake and New
Hanover-Pender County Medical Societies,
and the American Medical Association. He
served as president of the North Carolina
Medial Society in 1991-92 and is a member
of the Society’s Executive Council and an
alternate delegate to the American Medical
Association’s House of Delegates. He has
NCMB Elects Officers:
John T. Dees, MD, President;
Charles L. Garrett, Jr, MD, President Elect;
Mr Hari Gupta, Treasurer; Stephen M. Herring, MD, Secretary
also been an active participant in civic affairs
in Burgaw and Pender County and at the
state level.
Dr Dees was first named to the Board by
Governor James B. Hunt, Jr, in 1997. While
on the Board, Dr Dees has served, among
other committees, on the Complaints
Committee, the Physicians Health Program
Committee, the Investigative Committee,
the Clinical Pharmacist Practitioner Joint
Subcommittee, and the Executive
Committee. He currently chairs the
Licensing and PHP Committees. In 2000,
he was elected secretary-treasurer of the
Board. He served as the Board’s vice presi-dent
from November 2001 through October
2002.
Dr Dees says his philosophy is that
“service to humanity is the best work of
life.”
Charles L. Garrett, Jr, MD,
President Elect
Charles L. Garrett, Jr, MD, of
Jacksonville, served as the Board’s secre-tary/
treasurer through
October 2002 and
will become president
elect on November 1.
Dr Garrett is director
of laboratories at
Onslow Memorial
Hospital; managing
senior partner of
Coastal Pathology
Associates, PA; med-ical
director and
adjunct faculty member at the School of
Medical Laboratory Technicians at Coastal
Carolina Community College; medical
examiner of Onslow and Jones Counties;
southeastern regional pathologist for the
Office of the Chief Medical Examiner of
North Carolina; and executive director of
the Onslow County Medical Society. A
native of South Carolina, he received his
undergraduate education at Wofford College
in Spartanburg, SC, and took his MD,
magna cum laude, at the Medical College of
South Carolina in Charleston.
Dr Garrett did his postgraduate training
at the Medical University Teaching
Hospitals in Charleston, South Carolina,
and a fellowship at the Medical College of
Virginia and in the Office of the Chief
Medical Examiner of Virginia. He is certi-fied
by the American Board of Pathology.
He also served in the U.S. Navy, from which
he was honorably discharged as a lieutenant
commander.
A fellow of the College of American
Pathologists, the American Society of
Clinical Pathology, and the American
Academy of Forensic Sciences, Dr Garrett is
active in a large number of professional
organizations and served as president of the
North Carolina Medical Society in 1998. He
continues his work with the Medical Society
today in several capacities and is a Society
delegate to the American Medical
Association. He is also on the Board of
Directors of the AMA’s Political Action
Committee.
Among his many other professional activ-ities,
Dr Garrett has presented a number of
papers on forensic medicine to legal groups
in North Carolina and other states. In 1998,
Governor Hunt presented him the Order of
the Long Leaf Pine. He is very active in
church and civic affairs in Jacksonville.
Appointed to the North Carolina Medical
Board in January 2001, he has been a mem-ber
of the Board’s Investigative and
Executive Committees, and chairs the Policy
and Legal Committees.
Mr Hari Gupta, Treasurer
Mr Hari Gupta, of
Morrisville, was born
in London, England,
and grew up in
Vancouver, British
Columbia, Canada.
He earned two bache-lor
of science degrees,
one in computer
science and the
other in civil engineer-ing,
from Washing-ton
State University.
Mr Gupta began his professional career as
a programmer and systems analyst in
Toronto, Canada, and soon moved on to a
consultant’s post with the Computer Task
Group in Columbus, Ohio. In 1990, he
joined SAS Institute in Cary, North
Carolina, beginning as a software developer
and then moving to applications develop-ment.
In 1996, he became consulting direc-
Dr Dees
Dr Garrett
Mr Gupta
8 NCMB Forum
NCMB Elects Officers
continued from page 7
tor for SAS Asia Pacific/Latin America, and
doubled AP/LA consulting revenues for two
consecutive years. In 2000, he assumed the
role of general manager for SAS Global
Services, building and managing a 70-mem-ber
team of software consultants based in
India and the United States.
In 2001, Mr Gupta became director of
SAS Consulting Partners, responsible for
building and managing alliances with key
SAS partners and for developing and moni-toring
guidelines for the SAS Consulting
Partner program.
He left SAS in late 2001 to develop other
business interests. He is currently pursuing
a career in residential and commercial real
estate and is working on establishing a fur-niture
import business.
Mr Gupta was appointed to the Board in
February 2002. He has served on the
Board’s Legal and Complaints Committees
and will take his position as treasurer on
November 1, 2002.
Stephen M. Herring, MD, Secretary
Stephen M. Herring, MD, of Fayetteville,
a native of Chapel Hill, North Carolina,
took his BA degree at the University of
North Carolina, Chapel Hill. He earned a
DDS from the University of North Carolina
School of Dentistry,
followed by an MD
from the Wake Forest
University/Bowman
Gray School of
Medicine. He did his
internship in general
surgery and a residen-cy
in general surgery
and plastic surgery at
Bowman Gray. He is
certified by the American Board of Plastic
Surgery and holds licenses in both medicine
and dentistry.
Currently in the private practice of plastic
surgery in Fayetteville, Dr Herring is affiliat-ed
with Cape Fear Valley Medical Center
and Highsmith-Rainey Memorial Hospital.
He is a member of the American Society of
Plastic and Reconstructive Surgeons and is
active in state and local professional organi-zations.
He is also a past president of the
Cumberland County Medical Society and
author and co-author of several journal arti-cles.
Dr Herring was first named to the Board
in 1998. He has served on several Board
committees and currently serves on the
Policy Committee and chairs the
Investigative Committee. He will assume
the position of Board secretary on
November 1, 2002. continued on page 9
Dr Herring
The Intersection of Public Health and Pharmacy
for Older Adults: Making Sure That “Doctors’
Orders” Can and Should Be Followed
Gina Upchurch, RPh, MPH
Executive Director, Senior PHARMAssist
In the age of dimin-ishing
reimbursement
for patient care and
increasing emphasis on
“productivity,” more
health care providers
are opting not to
accept new Medicare
patients. Older adults
often have multiple
chronic conditions and
are taking multiple medications, requiring
more than the allotted time for appoint-ments.
While many providers feel rushed
and dissatisfied with current reimbursement
models, the Medicare payment structure
isn’t likely to reverse direction anytime soon
given the current economic forecast and the
lack of prevention foresight.
Providers’ lack of face-to-face time with
seniors is also a growing concern for com-munity
pharmacists who are being relegated
to deciphering insurance or “discount” cards
and filling more and more prescriptions as
reimbursement rates per prescription shrink.
It is projected that annual outpatient pre-scriptions
will grow to 3.13 billion in 2002,
and sales for these medications will exceed
$188 billion.1 This comes at a time of a
national pharmacist shortage, which may be
leading to more medication dispensing
errors as the sheer volume of prescriptions
and the plethora of “discount” cards over-whelm
community pharmacists.
If this shortage of time with seniors is not
a large enough public health concern, it gets
worse. In a recent survey of seniors con-ducted
by the Kaiser Family Foundation, the
Commonwealth Fund, and Tufts-New
England Medical Center in eight states, 22
percent of all seniors surveyed said they did
not fill a prescription because it was too
expensive or that they skipped doses of their
medications to make them last longer. For
the seniors who lacked prescription cover-age,
35 percent skipped doses or did not
have prescriptions filled. Therefore, a med-ication
could have been properly prescribed
and dispensed, and yet the expected out-come
is out of reach. Even prescription “cov-erage”
is not an assurance of medication
adherence. Close to one in four seniors in
the survey (including many with prescrip-tion
coverage) reported spending $100 per
month on their medications in 2001, which
is a significant financial challenge for many
seniors with fixed, limited incomes.2
In addition to reimbursement barriers for
health care providers working with seniors,
and the inability of many seniors to afford
the medications prescribed for them, many
older adults are receiving medications they
do not need and, in fact, may be causing
harm. It is projected that for every $1 spent
paying for medica-tions
in the ambula-tory
setting in the
U.S., we spend $1.36
dealing with medica-tion-
related problems
in this same popula-tion.
3 Fortunately,
many of these prob-lems
can be avoided
when the patient,
provider, and phar-macist
work together to ensure that every-one
is on the same “medication page.”
While there are definite limitations within
the health care system that currently do not
support the comprehensive treatment of
older adults with multiple concerns, there
are, nonetheless, many providers who effec-tively
handle the issues of limited time and
of medication payment and appropriateness
to ensure high quality care for their older
patients. In this age of advanced technology,
I would like to highlight some of the issues
involved with prescribing for older adults,
along with a few inexpensive, low-tech
methods that health care providers can
incorporate into their practices to ensure
that the medications prescribed are taken
appropriately and bring more good than
harm.
Polypharmacy and Medication
Inappropriateness
In 1998, people over the age of 65 com-prised
13 percent of the U.S. population, yet
they consumed 34 percent of prescription
medicines ordered, which represented 42
percent of prescription expenditures.4 While
polypharmacy (the use of multiple medica-tions)
may be necessary and beneficial,
sometimes it is a result of a senior having
Ms Upchurch
“Many older
adults are
receiving med-ications
they do
not need and,
in fact, may be
causing harm”
No. 3 2002 9
continued on page 10
Pharmacy
continued from page 8
multiple providers and pharmacists, with no
one provider having a complete picture of all
the medications a senior may be taking,
including prescription, over-the-counter, and
herbal products. In a nationwide survey con-ducted
in 2000, community-dwelling
seniors reported filling 28.5 different pre-scriptions
on average over the course of a
year.5 Polypharmacy seems particularly trou-blesome
upon hospital discharge when the
discharge summary and prescriptions are not
written by the provider who follows the
senior in the community. Even if the regular
community provider discharges the patient,
seniors are often confused about how to
“merge” discharge medications with their
regular medications, possibly leading to
inappropriate drug regimens.
There is an increased risk of adverse effects
and drug interactions as the number of med-ications
increases. While many drug-drug
interactions are not clinically significant,
many are. In addition, there are drug-dis-ease
interactions (ie, arthritis medicines that
can worsen GERD) and drug-nutrient inter-actions
(ie, less levothyroxine absorption if
taken within a few hours of calcium) that
can negatively affect the lives of older adults.
Polypharmacy is not a prerequisite for
medication-related problems in the elderly;
one medication can decrease the quality of
life for a senior. Findings from the 1996
Medical Expenditure Panel Survey indicated
that 21.3 percent of noninstitutionalized
elderly in the U.S. received 1 of 33 poten-tially
inappropriate medications. In fact, the
study likely underestimated the “inappropri-ateness”
of medication use in the elderly, as it
only used explicit criteria developed by Beers
and colleagues (a list of 33 medications) and
did not include dosage, dosing intervals,
indication criteria, or duplicate therapy.6
While more clinical trials are beginning to
include older adults, the complexity of the
study design necessitates that seniors with
several co-morbidities taking multiple med-ications
(confounders) be excluded from
many of the studies. Unfortunately, in real
life, there are older adults with multiple
problems and pharmaceutical remedies
swirling around when new agents are added
to the mix. Post-marketing surveillance is
critical for understanding the effects of med-ications
in the elderly.
Attach to the hectic health care provider
scenario the fact that very few health care
providers have any formal training in geri-atrics
and geriatric pharmacology, and we
have a dangerous intersection where phar-macy
meets public health.
Pharmacology and Adherence with
Older Adults
Older adults differ from younger cohorts
in two major ways with regard to pharma-cokinetics.
While there is individual varia-tion
among the senior population, two gen-eralizations
remain: 1) renal function
declines with age, and 2) hepatic function
(especially Phase I metabolism) is decreased
in the elderly. Some medications that are
eliminated primarily by the kidney, which
may need to be adjusted in an older individ-ual,
even with a normal creatinine, include
metformin, digoxin, allopurinol, lithium,
and amantidine. Medications that depend
on Phase I metabolism (eg, hydroxylation,
oxidation, etc) include several of the benzo-diazepines
(eg, flurazepam, triazolam,
diazepam), making them less appropriate for
use in the elderly.
In addition, clinical experience demon-strates
that many older adults are simply
more sensitive to the effects of medications
than the younger cohorts, who are often
included in the clinical trials. The senior’s
“reserve” for avoiding adverse effects is more
limited. For example, medications with
anticholinergic side effects may be a small
nuisance to a young person (ie, dry mouth);
however, anticholinergics may significantly
impair an older person (ie, mental confu-sion,
urinary retention, constipation, ortho-static
hypertension, etc).
After a medication is appropriately pre-scribed
and dispensed, medication adminis-tration
and adherence are usually left up to
the senior and his or her caregiver.
Medication adherence is a means to an end,
not an end unto itself. Twenty years ago,
Cooper and colleagues found that seniors
were no more or less adherent than younger
adults when matched for complexity of drug
regimen. And interestingly, when older
adults were non-adherent, 90 percent of the
time they underused the medication and 73
percent of the underuse was intentional.
Many of the seniors noted that they did not
perceive a need for the medication at all or in
the dosages prescribed.7 They also cited side
effects and the growing concern that “I sim-ply
cannot afford it.” In fact, sometimes
nonadherence is justifiable and appropriate.
The key is that these circumstances need to
be exposed and, if possible, alternative ther-apies
begun that satisfy the side effect and
pocketbook profile. This can happen with
honesty, rapport, and time.
Clash Between Rising Expenditures
and Our Ability to Pay
Medication expenditures have risen at
double-digit rates during the last few years.
In 2000, 42 percent of the year’s 18.8 per-cent
rise was attributed to an increase in the
number of prescriptions written, 36 percent
was attributed to a shift to the use of more
expensive medications, and 22 percent was
due to actual price increases from the previ-ous
years.8 Approximately 10 percent of our
health care dollars are spent on medications,
but these expenditures are rising much faster
than other segments in health care. While
much has been said about the massive
increase in direct-to-consumer advertising,
roughly 50 percent of advertising dollars are
spent on medication samples of the newest
medications.9 Many providers try to help
their seniors who struggle financially by
using their sample cabinets as pharmacies. In
addition, many providers are willing to help
access medications for seniors and others
who cannot “foot their pharmacy bill” by
applying for medications via the drug manu-facturers’
patient assistance programs. These
ever-changing programs, which are manu-facturer
specific and sometimes drug specif-ic,
combined with the newer “discount”
cards, create a new level of “service” in the
providers office. With decreasing reim-bursement
and, thus, less time with patients,
many providers are reluctant to embrace the
challenge of completing additional paper-work
to ensure access to medications.
What Is a Provider To Do? Practical
Tips for Working with Older Adults
In many instances, older adults are pre-scribed
appropriate and necessary medica-tions,
and pharmacists dispense the medica-tions
correctly and provide counseling at the
pharmacy counter. However, there is anoth-er
critical partner in this scenario: the
patient. In fact, in the prescribing-dispens-ing-
administering triangle, there are at least
three people—the provider, pharmacist, and
patient—and many times, nurses, social
workers, caregivers, and others involved.
There are several ways to strengthen the pre-scribing-
dispensing-administering triangle.
1. Bear in mind that “any symptom in an
elderly patient should be considered a
drug side effect until proved otherwise.”10
Discontinue medications that are no
longer needed and be vigilant about mon-itoring
for side effects. Before prescribing
a medication, make sure that what is being
treated is not an adverse effect from
another medication.
2. Consider whether adding a new med-ication
to a senior’s regimen is necessary,
even if she or he comes with a particular
drug name in mind and even if your writ-ing
a prescription may speed up the inter-view.
Consider whether other alternative
forms of treatment (eg, smoking cessation
10 NCMB Forum
continued on page 11
counseling, nutrition counseling, Kegel
exercises, etc) or simply explaining the
benefits of not adding a drug to the cur-rent
regimen is truly “the best medicine.”
3. Educate yourself about the cost of drug
therapies and ask your patients if they are
able to afford their medications. If they
need help, consider whether there are
cheaper alternatives or other resources
that you can use to ensure that the pre-scribing-
dispensing-administering triangle
doesn’t break down because of practical
decisions that your patients have to make.
A close relationship with a community
pharmacist may prove invaluable in this
regard.
4. Adopt the geriatric mantra: “Start low
and go slow.” When prescribing a med-ication
for an older adult, a general rule is
to add one medication at a time and begin
with low doses and slowly increase the
dose as necessary. The same could be said
for withdrawing a medication with CNS
effects: slowly decrease the dose before
discontinuation.
5. Ensure that accurate labels are on pre-scription
bottles. If you change the dose
or directions for administration, write a
new prescription. This will help the
senior or caregiver who may struggle to
remember the myriad of directions. In
addition, it will allow the pharmacist to
correctly counsel the patient, thus rein-forcing
the intended use of the medication
rather than serving to confuse.
6. Place the indication for the medication
on the prescription if at all possible. This
will help the patient and pharmacist
understand the use of the medication.
The pharmacist cannot type the indication
for a medication on a label (even if it is
obvious) unless the indication is on the
prescription. Seniors on multiple medica-tions
may have a difficult time remember-ing
the indications for their medicines
without help from the labels.
7. Write both the generic and brand name
of a medication on the prescription (and
label) to help prevent duplicate therapy,
especially when multiple providers and
pharmacies are involved.
8. Ask all of your patients to carry a list of
all their medications, including prescrip-tion,
over-the-counter, and herbal prod-ucts,
with them at all times. In addition,
ask your patients to show this to any and
all providers before anything gets added
to the list. Adding past medication aller-gies,
adverse effects, and the names of cur-rent
providers and pharmacies can be very
beneficial.
Pharmacy
continued from page 9
9. Ask open-ended questions about med-ication
administration and have “show
and tell” with medicines to ensure proper
medication schedules and administration
techniques. “You take this twice a day—
right?” may elicit a very different response
than, “Tell me how you actually take your
blood pressure medication.”
10. Try to determine if older adults are
included in the drug clinical trials you
review and, if so, consider whether the
study population is similar to the people
you treat.
11. Simplify drug regimens as much as
possible. Can “take the medication every
six hours” be changed to “take after each
meal (after you have checked that they do
indeed eat three times a day) and before
bedtime”?
At times, the barriers to providing good
medical care to older adults, including time,
costs, and other resources, can seem over-whelming
to the busy health care provider.
While most of the ideas on this list sound so
simple, incorporating them into practice can
make a major difference. Given that many
senior “encounters” are short on time, but
vast in need, your willingness to be attentive
to medication problems and costs can drasti-cally
improve the lives of your “chronologi-cally
gifted” patients.
_____________________
References
1. National Association of Chain Drug Stores
Weekly Report, 8/26/02.
2. The Henry J. Kaiser Family Foundation, The
Commonwealth Fund, Tufts-New England
Medical Center. Seniors and Prescription Drugs:
Findings from a 2001 Survey of Seniors in Eight
States. A Report, July 2002.
3. American Society of Consultant Pharmacists.
Seniors at Risk: Designing the System to Protect
America’s Most Vulnerable Citizens from
Medication-Related Problems. A Report, March
2002.
4. Families USA. Cost Overdose: Growth in Drug
Spending for the Elderly, 1992-2010. A Report, July
2000.
5. HealthDesk Survey (sponsored by Newshour
and Henry J. Kaiser Family Foundation),
September 2000.
6. Zhan C, Sangl J, Bierman AS, Miller MR,
Friedman B, Wickizer SW, Meyer GS. Potentially
Inappropriate Medication Use in the Community-
Dwelling Elderly. JAMA, 2001: 286(22):2823-9.
7. Cooper JK, Love DW, Raffoul PR. Intentional
Prescription Nonadherence (Noncompliance) by
the Elderly. JAGS, 1982;30(5):329-33.
8. National Institute for Health Care
Management (NIHCM) Research and
Educational Foundation. Prescription drug expendi-tures
in 2000: the upward trend continues. A
Report, 2001.
9. The Henry J. Kaiser Family Foundation.
Prescription Drug Trends—A Chartbook Update. A
Report, November 2001.
10.Gurwitz J, Monane M, Monane S, Avorn S.
Brown University Long-Term Care Quality Letter,
1995.
Senior PHARMAssist is a community-based,
nonprofit organization in Durham
County that complements the work of busy
providers and community pharmacists and
addresses many of the issues raised in the
previous article. The program was designed
to help seniors with incomes just above
Medicaid eligibility remain as active and
independent as possible for as long as possi-ble.
Since June 1994, Senior PHARMAssist
has helped over 900 seniors in Durham
directly with medication management, pre-ventive
health measures, and financial assis-tance
with their medications. An evaluation
published in the North Carolina Medical
Journal demonstrated that 30 percent more
participants knew the indications for their
medications, 29 percent fewer participants
stayed overnight in hospitals, and 31 percent
fewer participants visited emergency rooms
after being enrolled in Senior PHARMAssist
for one year.* These seniors had incomes
at or below 150 percent of the federal
poverty level (currently $1,108/single or
$1,493/couple), lived in Durham, and had
no other prescription insurance. Senior
PHARMAssist has helped an additional
2,400 individuals with either medication
management or improved access to medi-cines
via tailored referral to the drug manu-facturers’
patient assistance programs,
Medicaid, TriCare for Life, and other phar-macy
and health care programs.
Senior PHARMAssist:
• educates Durham County senior adults
about preventive health measures;
• consults with seniors and health care
providers about safe and effective medica-tion
use;
• provides financial assistance for neces-sary
medications to seniors with limited
incomes; and
• develops partnerships with others that
share its mission.
For further information about Senior
PHARMAssist see: Upchurch GA, Menon
MP, Levin KS, Catellier DJ, and Conlisk
EA. Prescription Assistance for Older
Adults with Limited Incomes: Client and
Program Characteristics. J PharmTechnol,
January/February 2002; 17:6-11. Also,
access the Senior PHARMAssist Web site at
www.seniorpharmassist.org.
NCMB Revises Two Position Statements
At its meetings in July and August 2002,
the North Carolina Medical Board complet-ed
work on and approved revisions of two of
its position statements. These revisions are
further refinements of changes made in the
same statements earlier in the year. They are
presented below in marked versions to clear-ly
indicate the changes made. Added lan-guage
has been underlined. Deleted lan-guage
has been lined through.
WRITING OF PRESCRIPTIONS
• It is the position of the North Carolina
Medical Board that prescriptions for con-trolled
substances or mind-altering chem-icals
should be written in ink or indelible
pencil or typewritten or electronically
printed and should be manually signed by
the practitioner at the time of issuance.
Quantities should be indicated in both
numbers AND words, eg, 30 (thirty).
Such prescriptions must not be written on
presigned prescription blanks.
• Each prescription for a DEA controlled
substance (2, 2N, 3, 3N, 4, and 5) should
be written on a separate prescription
blank. Multiple medications may appear
on a single prescription blank only when
none are DEA-controlled.
• No prescriptions, including those for
controlled substances or mind-altering
chemicals, should be issued for a patient
in the absence of a documented physician-patient
relationship.
• No prescription for controlled sub-stances
or mind-altering chemicals should
be issued by a practitioner for his or her
personal use. (See Position Statement
entitled “Self-Treatment and Treatment of
Family Members and Others with Whom
Significant Emotional Relationships
Exist.”)
• The practice of pre-signing prescriptions
is unacceptable to the Board.
• It is the responsibility of those who pre-scribe
controlled substances to fully com-ply
with applicable federal and state laws
and regulations. Links to these laws and
regulations may be found on the Board’s
Web site (www.ncmedboard.org).
• A physician who prescribes controlled
substances should pay particular attention
to the part of the Code of Federal
Regulations dealing with prescriptions,
which may be found at 21 CFR 1306,
entitled “Prescriptions.”
(Adopted May 1991, September 1992)
(Amended May 1996; March 2002; July
2002)
LASER SURGERY
It is the position of the North Carolina
Medical Board that the revision, destruction,
incision, or other structural alteration of
human tissue using laser technology is
surgery.* Laser surgery should be per-formed
only by a physician or by a licensed
health care practitioner working within his
or her professional scope of practice and
with appropriate medical training function-ing
under the supervision, preferably on-site,
of a physician or by those categories of prac-titioners
currently licensed by this state to
perform surgical services.
Licensees should use only devices
approved by the U.S. Food and Drug
Administration unless functioning under
protocols approved by institutional review
boards. As with all new procedures, it is the
licensee’s responsibility to obtain adequate
training and to make documentation of this
training available to the North Carolina
Medical Board on request.
Laser Hair Removal
Lasers are employed in certain hair-removal
procedures, as are various devices
that (1) manipulate and/or pulse light caus-ing
it to penetrate human tissue and (2) are
classified as “prescription” by the U.S. Food
and Drug Administration. Hair-removal
procedures using such technologies should
be performed only by a physician or by a
licensed health care practitioner working
within his or her professional scope of prac-tice
and with appropriate medical training
functioning under the supervision, prefer-ably
on-site, of a physician who bears
responsibility for those procedures. an indi-vidual
designated as having adequate train-ing
and experience by a physician who bears
full responsibility for the procedure. The
responsible supervising physician should be
on site or readily available to the person
actually performing the procedure.
*Definition of surgery as adopted by the NCMB,
November 1998:
Surgery, which involves the revision, destruction,
incision, or structural alteration of human tissue
performed using a variety of methods and instru-ments,
is a discipline that includes the operative
and non-operative care of individuals in need of
such intervention, and demands pre-operative
assessment, judgment, technical skills, post-opera-tive
management, and follow up.
(Adopted July 1999)
(Amended January 2000; March 2002;
August 2002)
No. 3 2002 11
John T. Dees, MD, a member of the
North Carolina Medical Board since
1997, was honored on October 18 by
Duke University Medical Center and
the Duke Medical Alumni Association
at a special Awards Luncheon held at
the Washington Duke Inn in Durham.
Dr Dees was one of three honorees
receiving the 2002 Distinguished
Alumnus Award. Present for the award
were Sheila Moriber Katz, MD, MBA,
President of the Duke Medical Alumni
Association; Ralph Snyderman, MD,
Chancellor for Health Affairs; and
R.C. Waters, Vice Chancellor for
Special Projects.
In their letter to Dr Dees, Dr Katz,
Dr Snyderman, and Dr R. Sanders
Williams, Dean of the School of
Medicine and Vice Chancellor for
Academic Affairs, wrote: “The leader-ship
of the Medical Center and the
Medical Alumni Association are very
proud of your accomplishments. You
have brought honor to Duke
University Medical Center as an alum-nus,
and it will be a pleasure for us to
recognize your achievements. . . .”
Dr Dees, who served as president of
the North Carolina Medical Society in
1991-92, will assume the presidency of
the North Carolina Medical Board in
November 2002.
Dr Dees Honored
by Duke University
Medical Center
John T. Dees, MD
_____________________
* Catellier DJ, Conlisk EA, Vitt CM, Levin KS,
Menon MP, Upchurch GA. A Community-Based
Pharmaceutical Care Program for the Elderly
Reduces Emergency Room and Hospital Use.
NCMJ, March/April 2000; 61(2):99-103.
Senior PharmAssist
continued from page 10
continued on page 13
Increasingly,
that is precisely
what is happening
to the relationship
between doctors
and patients.
Whatever the
underlying cause
may be, patients
are complaining
more frequently
that their physi-cians
are insensitive, arrogant, don’t listen,
are short-tempered, and simply don’t care
about the patients or their problems. Of
course, this does not happen in the majority
of the cases. The patient/doctor relationship
is as solid as ever most of the time.
However, an increasing number of com-plaints
to the Board by patients or those
responsible for them indicate that alarming
changes are occurring, both in reality and in
perception, that suggest that practitioners
are not putting enough effort into establish-ing
and maintaining their relationship with
their patients. The best technical training in
the world occurs here in the good old
U.S.A., but it goes for naught if communi-cation
with patients suffers.
Effective Communication
It has been estimated that approximately
90 percent of our communication is non-verbal,
and that highly effective people
spend a significant amount of time and ener-gy
listening (Covey, 1989). Many psycholo-gists
also feel that the ability to listen and
understand is one of the highest forms of
intellectual behavior.
It has been estimated that during her or
his average career, a physician/practitioner
will have over l00,000 visits with patients.
Obviously, what takes place most of the time
in those encounters is conversation.
However, the automatic assumption that
conversation is communication must be
tempered with the realization that, although
we say we are listening, we are likely rehears-ing
in our heads what we are going to say
when the other party is finished talking.
The effective listener must acquire the skill
of focusing on the patient and concentrating
on the verbal and nonverbal aspects of what
the patient is trying to communicate.
Unfortunately, although more medical
schools are offering courses in communica-tion
skills, this is still a difficult task. The
physician is frequently challenged to diag-nose
difficult cases with very limited infor-mation,
particularly if there is a language
barrier added to the equation. Under the
circumstances, in such situations, it’s
remarkable that we do as well as we do,
given the likely complications in communi-cations
that occur on a day to day basis.
The Other Person’s Footsteps
There have been several articles offered in
the Forum over the years aimed at helping to
reduce the incidence of complaints, but in
the complicated dynamics of today’s practice
it is increasingly difficult to meet the pres-sures
of the tight schedules, cultural differ-ences,
etc, and still keep patients contented
and feeling welcome and well-informed.
A short time ago, I happened on a film on
television titled “The Doctor.” It told the
story of a successful physician who was so
busy in his practice, and so wrapped up in
his own pursuits, that he lost sight of the
need for relating to his patients and col-leagues.
He became insensitive, abrasive,
and even arrogant in his outlook, and his
relationships suffered accordingly. Sound
familiar?
Then the doctor was stricken with cancer.
As he suffered through his illness, he started
out as a terrible patient, but he gradually
learned through his personal experience
what illness was like from the patient’s per-spective.
Fortunately, he survived and even-tually
recovered completely. He also went
through a profound transformation in his
own outlook and attitude. He found that
his subsequent encounters and relationships
with his patients, colleagues, and students
were similarly transformed. The insensitivity,
abrasiveness, and arrogance were gone,
replaced by humility, caring, and compas-sion.
I believe this film should be required
viewing for everyone, as it communicates so
eloquently the benefits of “walking a mile in
the other person’s footsteps.”
This is, of course, another example of the
Golden Rule, but in light of the number of
complaints from patients, and occasionally
from other professionals, regarding “com-munications”
problems, it prompts the ques-tion:
is your attitude getting in your way?
Communication and Complaints
As a member of the Board’s Complaint
Committee, I’m privileged to see firsthand
the complaints we receive about our
Is Your Attitude Getting in Your Way?
Aloysius P. Walsh, Chair
NCMB Complaint Committee
licensees, complaints that regrettably are on
the increase. There are a number of reasons
for this increase, of course, including
patients’ growing desire to participate in
treatment decisions and their willingness to
question and to challenge. And there is an
increasing awareness of the complaint mech-anism
open to them, easily available by call-ing
the Board or visiting the Board’s Web
site at www.ncmedboard.org. However, a very
substantial portion of the increase is due to
communications issues, including insensitiv-ity,
rude staff members, unwillingness to lis-ten,
abrasiveness, and even arrogance on the
part of the practitioner or physician. These
are the types of complaints that can be virtu-ally
eliminated. An ego suppressant, an infu-sion
of compassion, and a large dose of
humility is a great place to start.
Although many practitioners are gifted
with the characteristics that constitute what
we call a good “bedside manner,” for those
lacking the requisite gifts, there is a shortfall
in the amount of train-ing
to acquire the
skills aimed at filling
the gaps. Training in
communications, sen-sitivity,
etc, is readily
available, of course,
but it is not always
included in full mea-sure
in our medical
education programs,
nor is it sought out by
those who may be in the greatest need of
developing those skills, particularly those in
denial! Denial is frequently due to an atti-tude,
and attitude is a choice.
There are any number of articles in med-ical
and legal journals that speak to commu-nications
problems as a leading cause for
complaints and malpractice suits, and the
development of a good bedside manner
tends to have an insulating and even a reme-dial
effect, though it is not a sure cure. The
acquisition of a skill must be accompanied
by the right attitude to be effective in the
long term.
Staff Involvement
Involving one’s staff in the process of
developing and maintaining good patient
relationships also calls for considerable lead-ership.
Employees should be made fully
aware of the importance of good communi-
Mr Walsh
“The ability to
listen and
understand is
one of the
highest forms
of intellectual
behavior”
12 NCMB Forum
Your Attitude
continued from page 12
cations with patients. Self-improvement and
advancement opportunities should reflect
that commitment. Clear lines of communi-cation,
including a path for feedback with-out
fear of reprisal, should be in place to
assure communications in the office are
effective in supporting communications
with patients. Staff should be kept well
informed about practice matters and what is
expected of them; and regular performance
evaluation of staff should include a signifi-cant
communications element. Remember,
from the patient’s perspective, staff attitude
reflects practice attitude.
The practice that is focused on the well-being
and satisfaction of the patient stands a
much better chance of success. Patient sur-veys,
conversations
with patients that
include empathic
listening, and seek-ing
patients’ input
(not just telling
them what you
want them to do)
are much more like-ly
to result in a con-tented
patient.
Remember, com-munications
is a two-way process involving
both sending and receiving. Simply listen-ing
is probably the best single thing you can
do, particularly with an angry patient who
mostly needs to let off some steam. If he or
she feels you’re really interested, a potential-ly
explosive situation can often be defused.
Responding with hostility or defensiveness
practically guarantees a similar reaction from
the patient. Whatever the situation, your
own negative reaction really reflects your
own weakness, and suggests a lack of humil-ity
on your part.
Less Talking, More Listening
Various authors have offered helpful hints
over the years for more effective listening.
Davis (1967) suggested that, first, you stop
talking, show that you want to listen,
empathize, be patient, stop talking, hold
your temper, go easy on argument and criti-cism,
ask questions, and, last, stop talking.
DeMare (1968), among other things, fur-ther
suggests that you put the speaker at
ease, hear the patient through, be prepared
on the subject, make allowances for circum-stances,
avoid getting sidetracked, summa-rize
basic ideas, and restate the substance of
what you have heard. Golen(1990) also
opined that bad listeners are lazy, closed
Rate Your Listening Level
“Bad listeners
are lazy, closed
minded, opinion-ated,
insincere,
bored, and inat-tentive”
minded, opinionated, insincere, bored, and
inattentive!
Since good listening skills are more
important than ever, we offer a brief quiz at
the end of this article to help you rate your
listening level, which is key to having a car-ing
and compassionate bedside manner.
Conclusion
In closing, I would offer a couple of brief
additional suggestions. First, keep in mind
that your purpose, first and foremost, is tak-ing
care of patients, and you would do well
to park your ego in the garage or parking
lot, and make humility and compassion a
large part of your diet. Second, remember
that your patients may not recall clearly what
you say or do to them, BUT THEY WILL
NEVER FORGET HOW YOU MADE
THEM FEEL.
E-Mail:
info@ncmedboard.org
Web Site:
www.ncmedboard.org
North Carolina Medical Board
No. 3 2002 13
Do you look at the person with whom
you are speaking?
Do you withhold judgment until the
speaker is finished?
Do you like to listen to other people
talk?
Do you listen even if you do not like
the person?
Do you ask what the words mean if
you don’t know?
Do you ask questions in order to fully
understand?
Do you listen regardless of choice of
words and manner?
Do you actively think about what is
being said?
Do you put aside thought of what you
have been doing?
Do you listen equally to men, women,
young and old patients?
Do you stay aware of gestures,
inflections, and other clues?
Do you ignore distractions while listen-ing?
Do you let the speaker finish?
If the speaker hesitates, do you
encourage him/her to go on?
Do you re-state what has been said to
make certain you understand?
Do you listen even when you
anticipate what will be said?
Do you give your full attention to the
speaker?
Do you take notes while listening?
1
Never
2
Sometimes
3
Often
4
Always
How would you rate yourself as a listener? Answer the following questions by checking
the term that most accurately describes your usual behavior.
Total possible score: 72. 72-65: Artful listener. 64-59: Good listener. 58 or below:
Listening skills need work; negotiating with patients (or anyone else) is probably
difficult.
[Printed with permission from Medical Management Institute]
continued on page 15
14 NCMB Forum
Physician Behavior
Nicholas E. Stratas, MD, LFAPA
Former Member, Former President, NCMB
Over the past 35
years, the public
and medical licens-ing
boards have
paid increasing
attention to behav-ior
of physicians.
Problems with
alcohol were the
initial focus and
the term “impaired
physician” was
coined and added to our vocabulary.1 While
substance-related disorders continue to be
the major focus, there is greater recognition
of mood disorders, relational disorders, par-ticularly
marital, and behaviors that are
“boundary violations,” sometimes simply
verbal and not necessarily physical.2
Recently, another group of physicians has
been labeled “the disruptive physician.”
There is decreasing tolerance for behaviors
that now thrust the physician into reviewing
and disciplinary processes that frequently
require a psychiatric evaluation.
These behaviors are varied and include,
among others, rudeness; loud, abusive or
demeaning language; abuse of staff, patients
or relatives; sexually offensive language or
behavior; aggressive behavior; presenting to
clinical settings with alcohol on the breath.
Patients, families, office and hospital staff,
administrators, and fellow physicians, even
within the same practice, complain to vari-ous
institutional bodies including hospital
medical staff, administration, and state med-ical
licensing boards. These behaviors are
not new, but focus on them is. In the past,
they would have been excused either on the
basis of the physician being a highly valued
healer, a special member of society, or with
rationalizations such as “he must have been
up all night” or “that’s the way he is, you
know.” The public has discovered we have
clay feet, most of us sleep well at night, and
there is no longer a willingness to anoint our
narcissism with oil.
What follows is based on my personal
experience as a psychiatrist in private prac-tice
seeing, on average, over 20 physicians a
year, some self-referred, others referred for
evaluation, some from medical organiza-tions,
some from the North Carolina
Medical Board (NCMB). In addition, dur-ing
my NCMB tenure, I had the privilege of
conducting hundreds of interviews with
physicians.3,4,5 I was also fortunate to be part
bine general practice and family practice,
then psychiatry is number two. General and
family practice are overrepresented in areas
of inappropriate prescribing, inadequate
supervision of physician extenders, changes
in hospital privileges, and insufficient
medical education. Psychiatry is prominent
because of boundary violations and sub-stance
abuse. These are three-year figures
and do not include NCPHP data.
Alabama has kept figures regarding the
primary clinical diagnosis of evaluations
done. Substance abuse problems lead at 61
percent. Affective disorders are next at 29
percent and personality disorders are third at
10 percent.
Private Practice
I first came to Raleigh as one of the earli-est,
if not the earliest, with a training back-ground
in cognitive behavioral as well as
psychodynamic work. Physicians who
became aware of this sought me out either
for themselves or their families, and I have
seen them in con-sultation
for indi-vidual,
couples, and
couples group ther-apy.
10 Over the
years, physician
referrals have
increased by word
of mouth. Prior to
my appointment to
the NCMB, I was
seeing more than a
dozen physicians a
year. During my
tenure on the NCMB, physician referrals
declined. Following my tenure, I have aver-aged
over 20 physicians per year. Two-thirds
are self-referrals. The other third were
referred for evaluation and report by hospi-tal
medical staffs, practice associates, attor-neys
for physicians who were being investi-gated
either by the NCMB or their own hos-pital
staff, and by the NCMB. I have also
been consulting with physician practices
regarding organizational and practice issues.
These contacts have given me an additional
window into the life and issues of physicians
and their families. Substance abuse cases are
being diverted now to twelve-step programs
and to addictionologists.
The problems triggering referral to me
are: neuropsychiatric—(37%); marital dys-of
the origination, start-up, development,
and initial board of the North Carolina
Physicians Health Program (NCPHP). I
also served on the NCPHP’s Clinical
Committee, which reviews all cases, many
anonymously. I also cite data from
Alabama.6,7
I will focus on the “disruptive physician.”
This term is reminiscent of the time we had
pejoratives such as the “drunk doctor” for
those now identified as having “substance-related
disorders,” many of whom have dis-ruptive
behavior but are not so labeled.
When I see these doctors, I do not find them
incompetent or bent on creating havoc.
Rather, they are generally suffering narcissis-tic
injury, are hurt, defensive, frightened,
angry, and even arrogant, but hardworking
and well-meaning. They feel misunderstood
and have not had a meaningful supportive
relationship. Other than substance-related
disorders or other psychiatric conditions, the
best way to identify and understand the fea-tures
of the physicians who present with dis-ruptive
behavior is through personality
makeup. My preferred nomenclature is
Disruptive Behavior Disorder of Adulthood
(DBD).
The North Carolina Medical Board
A review of the reasons physicians were
summoned to interviews with the NCMB
and of the number of actions taken by the
NCMB reveals inappropriate prescribing
was the most frequent cause, followed in
order by substance abuse, issues of medical
competence, malpractice events, psychiatric
condition, inadequate supervision of physi-cian
extenders, patient complaints, sexual
misconduct, changes in hospital privileges,
self-prescribing, insufficient medical educa-tion,
felony conviction, and unlicensed prac-tice.
Those reasons potentially affecting
behavior—substance abuse, psychiatric con-dition,
sexual misconduct, self-prescribing,
patient complaints, and felony conviction—
comprise a total of 46 percent of interviews
and 30 percent of actions.
In North Carolina, family and general
practice and psychiatry are the specialties
with the highest probability for interview
and discipline. Emergency medicine is a
specialty with increasing numbers.
The odds ratio for likelihood of interview
and for disciplinary action identifies psychia-try
as the fourth likely to be interviewed and
the third likely to be disciplined. If we com-
“In North
Carolina, family
and general prac-tice
and psychia-try
are the spe-cialties
with the
highest probabili-ty
for interview
and discipline”
Dr Stratas
No. 3 2002 15
continued on page 16
Physician Behavior
continued from page 14
function—(30%); disruptive behavior—
(21%); quality of care issues—(10%);
chemical abuse—(2%).
In self-referred physicians, marital dys-function
and affective disorders are the most
common problems. In marital dysfunction,
the primary driving dynamics arise out of
the underlying personality makeup, with
traits of narcissism, compulsivity, avoidance,
and histrionicity predominating, in that
order. This is supported by the Alabama
data. Of the physicians referred to me for
evaluation, the largest group is that of per-sonality
traits or disorders, followed by
affective disorders.
Disruptive Behavior
Of 14 physicians referred in the past two
years because of disruptive behavior, 10 had
a primary diagnosis of personality problems,
with patterns in order of prevalence: obses-sive-
compulsive, narcissistic, avoidant, and
histrionic. In addition, three had an affective
disorder, one abused alcohol and was depen-dent.
Single, separated, or divorced physi-cians
were overrepresented.
In physicians being evaluated generally,
affective disorders, personal-ity
disorders, and chemical
dependence are the most
common diagnoses, with
marital dysfunction fre-quently
the presenting prob-lem.
In the group with “dis-ruptive
behavior,” personali-ty
problems are the most
prevalent.
When evaluating physi-cians
with disruptive behav-ior,
differential diagnoses to
be considered include: substance related;
personality disorders; adjustment disorders;
sleep deprivation; bipolar disorder; other
medical problems; and organic brain disor-ders.
Of course, more than one may be pre-sent
at the same time. Moreover, biology is
increasingly identified as a factor in person-ality
disorders.12
Early warning signals for the physician
with DBD include: being unmarried; in solo
practice; lack of involvement in medical
organizations; overwork; marital infidelity;
increased alcohol intake; legal events; prac-tice
changes; complaints/malpractice/disci-plinary
events; clinical practice changes; clin-ical
disruptions; and lack of an organizing
belief system.
Physicians’ problems show up in their pri-mary,
personal relationships long before they
impact the practice and even before the
physician may be aware of the problem.8
The career is the last place where problems
appear. Physicians in solo practice are more
vulnerable than their colleagues who are in
group or institutional practices. The latter
are more likely to be self-referrals, appear
earlier in their difficulties, and avoid discipli-nary
processes.
Physician stressors, which occur with
some frequency, include: finances/decreasing
incomes; buyouts; mergers and closures of
practices and hospitals; managed care; over-work,
unhealthy competition for jobs; and
unhealthy competition for patients. Also
stressful are declining collegiality; physician-to-
physician marriage; difficulty with inti-macy;
self-medicating; the stigma of psychi-atric
problems; and decreased satisfaction.
Vignettes
The following case vignettes are illustra-tive.
Changes have been made, of course, to
protect identities.
Doctor A was a 45-year-old male surgeon
from the eastern part of the state, twice
divorced and the father of two children. He
was referred to me by the hospital medical
staff executive committee for aggressive
behavior, abuse of hospital staff nurses, and
unorthodox techniques.
Complaints had come to the
administrator from a surgeon
colleague and surgical nurses.
The administrator turned the
case over to the president of
the medical staff.
My evaluation revealed a
hard-working physician who
had continued to keep up
with CME, who was working
long hours, in solo practice.
Two physicians had come to
his practice and then left. He was practicing
in a town with few surgeons and had
become isolated from his colleagues. His
two teenagers, living with him, were doing
well. Substance dependence was suspected
but ruled out, and the impression was of
someone with mixed personality traits of
narcissism and compulsivity with significant
relational problems.
Recommendations were for psychothera-py,
involvement with organized medicine,
monitoring of a fixed number of cases, and
review in six months. He was initially angry
and defensive. However, as I interpreted the
evaluation, bringing out the dynamic issues
and focusing on his increased efforts to
“work harder and longer” as pressures
increased, thus increasing his isolation and
unawareness of his impact on relationships,
he became tearful and in touch with his sad-ness.
He opened up and expressed his need
for help. He is following through with the
recommendations and has done well.
Doctor B was a 58-year-old, recently wid-owed
primary care physician from a rural
area of the state with two grown, married
children. She was referred because of com-plaints
by the hospital nursing staff to the
administrator about her irritability and two
episodes of coming in to the hospital with
alcohol on her breath. She had rebuffed the
administrator’s referral to NCPHP. Her
anonymity was broken and her name was
given to the NCMB. They invited her to an
informal interview and then referred her to
me for evaluation. She had an excellent his-tory,
personally and professionally, but over
time had gradually decreased professional
contacts and stopped doing hospital work.
One year earlier, her husband of 33 years
had died after several months of illness. She
was drinking more than usual, but she was
neither dependent nor an abuser. In fact, she
had most of the criteria for major depres-sion.
Her underlying personality makeup
consisted of narcissistic and avoidant traits.
She was guarded at first, but wanting to
cooperate in the treatment plan that was rec-ommended,
including goal-oriented, cogni-tive
behavioral therapy; grief work; discon-tinuation
of alcohol and caffeine; and use of
antidepressants. She did very well and is no
longer depressed. She says she has “a new
lease on life,” is golfing with her friends and
children, traveling, and reinvolved with pro-fessional
colleagues. With my evaluation
report and follow-up in hand, the NCMB
saw her again in an informal interview and
took no further action.
As an aside, I have mentioned that I did
not think Doctor B was an alcohol abuser,
although she was accused of coming to the
hospital with alcohol on her breath.
Apropos of this, I should note that one of
my most recent referrals, from his attorney
and from NCPHP, was diagnosed at Rush
Presbyterian in Chicago as an abuser of alco-hol.
They based that diagnosis simply on
the record of his coming into the hospital
with alcohol on his breath on two occasions.
He said he had used alcohol several hours
before going to the hospital on both occa-sions
to help get to sleep. He did this on the
recommendation of a medical colleague sub-sequent
to several night shifts. He has a his-tory
of minimal and appropriate alcohol use.
Doctor C, a 40-year-old, single emergency
room physician, was referred to me by his
group practice associates because of com-plaints
received from patients and nursing
staff about his brusque and short behavior
and comments. He had been the subject of
“Physicians’ problems
show up in their prima-ry,
personal relation-ships
long before they
impact the practice and
even before the physician
may be aware of the
problem”
16 NCMB Forum
Physician Behavior
continued from page 15
a lawsuit that had gone against him. Initial
interview revealed a very compulsive
detailed individual who was obsessing
about the lawsuit that had been closed two
years earlier, about a failed relationship, and,
now, about being asked to have a psychiatric
consultation. He was in a very busy practice
and evidently had not had any problems
related to quality of care. Even the case set-tled
against him was peer reviewed and his
performance was found to be appropriate.
Although he did qualify for a diagnosis of
anxiety disorder, his primary problem was
his underlying compulsive personality. He
had been in psychotherapy years earlier and,
although it was brief, he recalled it as a pos-itive
experience. He was very defensive and
protective of information about himself. He
rejected out of hand any medications, and
therapy has been brief and episodic. He is
still in practice, having had no further com-plaints,
and is still single. However, he has
joined several social organizations and has
dated a woman he met there.
Discussion
My impression is that those who are orga-nized
and structured in such a way as to suc-ceed,
and who draw attention to their suc-cess,
have been more likely to be the suc-cessful
medical school candidates. A clearer
and more objective understanding of behav-ior,
personality traits, personality disorders,
and primary mental illness in those who
select medicine as their career as compared
to the general population is needed.
Moreover, medical students need workshops
regarding predominant personality patterns
that make for success and at the same time
create vulnerabilities.11 Increased sophistica-tion
regarding psychological patterns that
promote medicine as a career, increased
attention to the human element in medical
school, awareness of the importance of per-sonal
and family support systems, a sensitiv-ity
to early signals of increased neediness—
all will allow promotion of health and bal-ance
in the physician and early detection. It
seems that medicine is attractive to those
who have overcompensated with attitudes of
uniqueness and entitlement and who seek
admiration.
Patients’ needs, played out in their posi-tive
and negative transference, interact with
the physician’s needs. Traits such as narcis-sism
and compulsivity may interfere with the
sensitivity the physician must have to the
transference phenomena that are representa-tive
of the patient’s needs.14,15 A physician’s
over-sensitivity to demands and situational
pressures and threats to status can lead to
behavior and allegations that produce hurt,
anger, and projection. The compulsive
physician works hard and, when faced with
increased pressures or questions, can become
defensive, self-focused. As a result, he or she
can end up “working harder and longer.”
It behooves us, particularly in psychiatry,
to be comfortable and competent with the
physician as patient in stepping up to advo-cacy
issues as they develop with those in
authority relationships with the physician.
We must appreciate the anger in the
referred physician, which is inevitably pre-sent,
and encourage awareness of the sadness
and even fear that is frequently repressed and
likely related to early developmental history.
Sadness is the key to narcissism and the root
of tenderness. Use of letting-go techniques
and other cognitive behavioral skills are
important for obsessional and compulsive
individuals.
At times, confrontation is very important
and needs to be timely and not delayed. It
may even be necessary in the first interview.
On many occasions, my confrontation of the
physician with the statement that a given
behavior “is unacceptable” has been the
beginning of the necessary alliance for pro-ductive
work.
Physicians as a group do better than the
general population, even when they have
presented unwillingly as the result of pres-sure
or referral from someone else. I believe
this is because they have had a lifetime of
complying with structure and expectations,
because of the peer pressure inherent in the
process of evaluation and treatment of a
physician by a physician, and because the
medical career is, in most instances, an inte-gral
part of most physician’s self-image.
Finally, times have changed and physicians
are retiring in great numbers. Identification
and assessment of those who have retired
with a successful medical career without
patient complaints, disciplinary actions, liti-gation,
or evidence of decompensation prob-ably
provide an avenue for understanding
factors that have helped them and that need
to be applied in preventive and therapeutic
undertakings with physicians.
Summary
This article is based on my retrospective
and personal experience with the NCMB
and my private practice. Concern about the
“impaired physician” has been around for a
good while, focused on chemical abuse and
dependence, now with increased acknowl-edgement
of other psychiatric syndromes,
especially the affective disorders.
Complaints have emerged regarding behav-iors
including rudeness; disrupted patient
care; loud or abusive language; using instru-ments
as weapons; abusing staff, patients or
family; and sexually offensive behavior or
language. These behaviors are predominant-ly
related to personality patterns, including
compulsivity, narcissism, and avoidance, at
times associated with primary psychiatric
problems. These personality patterns are
likely active in the selection of and success
with a medical career. Frequently, marital
relational status and counter dependence are
factors. As with all patient transactions, the
patient-doctor alliance is the key to a suc-cessful
resolution. In the main, physicians, a
group with a lifelong pattern of success, have
a significantly higher success rate than the
general population.
_____________________
References
1. Report of the Ad Hoc Committee on
Physician Impairment, Federation Bulletin
1994;81:4:229-242.
2. Report of the Subcommittee on Sexual
Boundary Violations, Federation Bulletin 1996.
3. Stratas NE, Alexander E Jr, Paris BD Jr.
Function of the Board of Medical Examiners of
the State of North Carolina, North Carolina
Medical Journal 1992;53:11-12.
4. Paris BD Jr, Stratas NE. Complaint Review
Process of the Board of Medical Examiners of
the State of North Carolina, North Carolina
Medical Journal 1992;53:15-16.
5. Newton L, Stratas NE. Review of Informal
Interviews and Disciplinary Actions of the Board
of Medical Examiners of the State of North
Carolina, 1988-1991, North Carolina Medical
Journal 1993;54:625-632.
6. Summers GL, Ford CV, Lightfoot WM. The
Disruptive Physician, I: The Alabama Recovery
Network, Federation Bulletin 1997;84:236-243.
7. Ford CV, Summers GL. The Disruptive
Physician, II: The Role of Personality Factors,
Federation Bulletin 1998;85:20-29.
8. Stratas NE. Stress and the Physician’s
Family, Kentucky Medical Bulletin, 1993; August.
9. Stratas NE. Duke University Medical
Center, Psychiatry Grand Rounds, February
2000.
10. Stratas NE. Successful Partnerships,
“Mental Health Corner,” Wake County Physician,
1997, 4:18.
11. Stratas NE. Success and Stress in Physicians,
“Mental Health Corner,” Wake County Physician,
1998, 1:19.
12. Stratas NE. Biological, Psychological or
Social? “Mental Health Corner,” Wake County
Physician, 1999, 1:8-9.
13. Stratas, NE. The Doctor-Patient
Relationship—Changing, “Mental Health
Corner,” Wake County Physician, 2000, 1:7.
14. Stratas, NE. The Physician and Narcissism,
“Mental Health Corner,” Wake County Physician,
2000, 2:6-7.
15. Stratas, NE. The Physician and
Compulsivity, “Mental Health Corner,” Wake
County Physician, 2001, 2:45.
continued on page 18
of Government. Before she could take those
steps, however, the patient left town.
This true story suggests how important a
caring physician or other health provider can
be to a young woman experiencing an
underage pregnancy and to her family—and
suggests the value of a physician knowing
something about what a DSS can offer.
Thousands of girls 17 or younger
become pregnant every year in
North Carolina (7,227 in 2000)
and the great majority of them
become parents (5,415 in that
year). Since few of these very
young mothers marry or stay
in touch with their partner,
they look to trusted adults
both inside and outside the
family for assistance. Health
providers are one such
group of adults; DSS staff
is another.
A DSS can help girls
and families negotiate the
legal complexities of dif-ficult
circumstances.
Legal issues the agency
may become involved in
include the following.
• Can parents put a pregnant minor child
out of their home?
• What are a pregnant or parenting ado-lescent’s
rights to attend school or com-munity
college or, for that matter, to
work?
• Are teens responsible for their child’s
support? If not, who is?
• Does a foster child who becomes a
mother have a right to have her child
with her in foster care? If so, can she
take the child when she leaves at age 18?
• Can a DSS with custody of a minor who
is a mother and of her child fairly repre-sent
both?
A book on the legal aspects of adolescent
health care during pregnancy (Health Care
for Pregnant Adolescents: A Legal Guide) was
discussed here recently (Forum, #3, 2001)
and sent to approximately 8,000 health
providers, thanks to grants from the Z.
Smith Reynolds Foundation and the School
of Government, UNC, Chapel Hill. (The
health providers’ book can be printed from
www.adolescentpregnancy.unc.edu or pur-chased
from the Institute of Government,
919.966-4119.)
Now, a second volume, Social Services for
Pregnant and Parenting Adolescents: A Legal
Guide, has been published. Some physicians
may want this guide as well to help them
advise patients and their parents. Although
the book is primarily for DSS employees and
other social workers, a limited number of
copies is available without charge for physi-cians.
(To request a copy, e-mail Anne
Dellinger, dellinger@iogmail.iog.unc.edu, and
include a mailing address.) The
second guide may
also be printed
from the Web site
above.
The story that
opens this article is
typical in that even a
pregnant or parenting
girl who is mature,
bright, and competent
for her age probably
lacks some of the
resources needed now or
for the future: sufficient
income and education,
housing, transportation,
health insurance, employ-ment,
child care, and child
support among others. In
addition, as a minor she
lacks the ability under law to control most—
though not all—of her decisions. For these
clients, as well as for their parents and chil-dren,
a DSS is a crucial resource.
Under state law, a DSS may be called on
to protect a minor from abuse, neglect, or
dependency; to pass along to law enforce-ment
information about statutory rape,
domestic violence, or other crimes that may
have physically harmed a minor; perhaps to
act as a minor’s custodian, consenting to her
medical care in some instances or other
important matters; to seek termination of
her parents’ rights or of her own rights as a
parent; to find a home for her and perhaps a
child; or to help her place a child for adop-tion.
For minors who need less support,
DSS may still be the gateway to essential ser-vices
such as cash assistance, child support,
day care, Medicaid, or the food supplements
of the WIC program. Another possibility is
that a DSS will encounter a minor solely as
a parent when it undertakes for her child
some of the obligations mentioned above.
Federal law, too, requires that a DSS work
with unmarried pregnant teens and preteens
Social Services for Pregnant and Parenting Adolescents
Anne Dellinger, JD
Professor, Public Law and Government, Institute of Government
The University of North Carolina at Chapel Hil
This commentary continues Professor
Dellinger’s presentation of titles in the new
series on pregnant and parenting adolescents
being published by the Institute of
Government, the University of North
Carolina at Chapel Hill.
Professor Dellinger has been a faculty
member at the Institute since 1974. She
was formerly of counsel with Hogan &
Hartson, Washington, DC, and is author of
numerous publications on health and hospi-tal
law, including an article, How We Die in
North Carolina, in Forum #2, 1999. Her
article on the first volume in the Legal
Guide Series appeared in Forum #3, 2001.
Summer before
last, in early
August, a health
department nurse
asked what could
be done for one of
her patients, a 17-
year-old in late
pregnancy. The
nurse’s concerns
were not medical;
the young woman
had been keeping her appointments and was
healthy. Still, her problems were serious.
Months earlier, on discovering the pregnan-cy,
her mother had told the girl to leave, and
the patient made her way to a stepfather in
North Carolina. Here, she became semi-homeless.
That is, some nights the stepfa-ther
let her stay with him, but otherwise she
had difficulty finding a bed. The girl’s great-est
concern was
school. She had
been a very good
student, wanted
to do her senior
year here, and
hoped for a col-lege
scholarship.
However, the
local high school’s
registrar would
only enroll her if
the stepfather
came to school
between 8 AM and
noon on a weekday. He was a construction
worker and unwilling or unable to lose a
day’s pay to do it.
The nurse was advised to call the local
department of social services (DSS) and also
to talk with a school attorney at the Institute
“Thousands of
girls 17 or younger
become pregnant
every year in
North Carolina
(7,227 in 2000)
and the great
majority of them
become parents
(5,415 in that
year)”
No. 3 2002 17
Professor Dellinger
Social Services
continued from page 17
in numerous specific ways.
Like Health Care for Pregnant Adolescents,
the DSS book reviews the legal and medical
requirement to explain pregnancy options to
a patient so she can decide to continue or
end the pregnancy. It also describes the law
of emancipation, marriage for minors, the
process the General Assembly recently estab-lished
for surrendering a newborn, and basic
information for parents who are considering
placing a child for adoption. The guide
emphasizes DSS’s general legal responsibili-ties
to minor clients: protection, informa-tion,
advocacy, impartiality, and confidential-ity.
It contains sections on domestic violence
in adolescent relationships, on DSS direc-tors’
and employees’ personal liability, and
much broader coverage of parenting issues
than the health providers’ book. Possible liv-ing
arrangements for minors are discussed,
along with parents’ rights and duties, termi-nation
of parental rights, and how—and
why—a single mother should establish her
child’s paternity, seek to have the child legit-imated,
and obtain a child support order. As
a companion to the book, a resource list for
social services is posted on the Web site,
www.adolescentpregnancy.unc.edu.
Nota Bene
About the Legal Guide Series
Health Care for Pregnant Adolescents: A Legal Guide was published by the Institute of Government,
the University of North Carolina at Chapel Hill, in fall 2001. The second title in the series, Social
Services for Pregnant and Parenting Adolescents: A Legal Guide (discussed in the previous article), is
now available. A third guide will follow for public school employees; a fourth for parents of preg-nant
and parenting teens and preteens; and a fifth for adolescents themselves. Each will be
announced in the Forum when it is available.
Comments on Social Services for Pregnant and Parenting Adolescents:
A Legal Guide
“This handbook. . .is an impressive piece of work and I think will be very useful to county staff in
offering support to this population. Dellinger has done her research well.”
—David Atkinson, Division of Social Services, NC Department of Health and
Human Services
“I really like the tone. It’s clear and readable without telling busy caseworkers more than they need
to know.” —Gretchen Aylsworth, District Administrator, Guardian Ad Litem Program
“This document is wonderfully ‘pithy’—full of terrific info. I can only imagine the time and focus it
took!”
—Beth Brandes, Associate Director, Catawba County Department of Social
Services
“This is a great resource—easy to follow, informative, and non-judgmental.”
—Sharon Holmes, University of North Carolina at Chapel Hill School of Social
Work, former Director, Orange County Adolescent Parenting Program
“You have done an outstanding job with this and it will be an invaluable resource.”
—Tyrone Wade, Associate County Attorney/Mecklenburg
“No one had any comments except positive ones. We all found the guide to be very readable, clear,
concise, with information well organized. We can see where this manual will be a valuable tool for
us, as a supplement to policy and procedures already in place.”
—Sandra Wilkes, Director of Social Services, Rowan County
Each employer has a responsibility to
ensure that those licensed persons in their
employ are appropriately credentialed. One
should never accept just a presentation of the
wallet-sized card as validation of the person’s
licensure status. To validate that a nurse
holds a current license to practice in North
Carolina, call (919)-881-2272 or access our
Web site at www.ncbon.com and click on
“Verify License.” You will need the individ-ual’s
Social Security number or North
Carolina nursing certificate number to access
this system. If you are unable to verify the
license through one of these applications
(telephone verification or Web-based verifi-cation),
immediately call the Board of
Nursing for clarification at (919) 782-3211.
In addition, under North Carolina
General Statute 90-640, any health care
practitioner who is licensed, certified, or reg-istered
to engage in the practice of medicine,
nursing, or other health profession must
wear a badge or otherwise display in a read-ily
visible manner that person’s name and
licensure, certification, or registration title
when providing care to patients.
This year, the North Carolina Board of
Nursing has received an alarming increase in
the number of complaints related to persons
who represent themselves to the public as
licensed nurses when they do not hold, nor
have they ever held, a license to practice
nursing in North Carolina. These individu-als
have ranged from individuals working in
office-based practices who call themselves
“office nurse” to imposters who create and
present fraudulent documents indicating
they are licensed nurses.
North Carolina General Statute 90-
171.43 states: “No person shall practice or
offer to practice as a registered nurse or
licensed practical nurse, or use the word
‘nurse’ as a title for herself or himself, or use
an abbreviation to indicate that the person is
a registered nurse or licensed practical nurse,
unless the person is currently licensed as a
registered nurse or licensed practical nurse as
provided by this Article.” To practice nurs-ing
without holding a license is a violation of
the Nursing Practice Act; a misdemeanor in
North Carolina.
Just recently it came to the Board of
Nursing’s attention that an individual had
been employed in an office-based practice
for nine years as the “Chemotherapy Nurse”
even though this person had never been
licensed to practice as a nurse. Other indi-viduals
working in office-based practices
who represented themselves as nurses, but
did not hold, nor had they ever held, a
license to practice nursing have been report-ed
to the Board by consumers who are con-cerned
about the safety of care they receive.
The Board of Nursing requests your
support in helping protect the public by
ensuring that only appropriately licensed
individuals use the term “nurse” and that all
name badges include the proper licensure
credentials. Please confirm current licensure
by utilizing our automated verification
system as noted above. The public needs to
be assured that their health care providers
are properly licensed and wear name badges
that accurately present them to the public
they serve.
From The Board Of Nursing
The Importance of Verifying the Licensure Status of Nurses
Employed in Office-Based Practices
18 NCMB Forum
As our third year of state budget crisis
drags on, we all are taking a careful look at
our personal and professional lives for frugal
remedies. A significant component of recent
growth in state expenditures has been the
Medicaid program. This program provides
needed services to the most vulnerable in our
community and is absolutely essential to pre-serving
health and preventing catastrophic
illness and wasteful crisis health care expen-diture.
A significant component of the increased
expenditure has been pharmaceutical sup-plies,
with over one billion dollars commit-ted
to this essential function during the past
year. The growth in this component of the
state budget has been far greater than any
projections, partly due to the introduction of
new drugs and exciting new therapies.
These new therapies, however, often come
with a high price tag. The 2001 cost is stag-gering:
Celebrex® $21 million, Prilosec® $39
million, Oxycontin® $15 million, and Vioxx®
$15 million, to name a few. On the horizon
are exciting but costly new drugs, among
them recombinant growth hormone
(Serostim®) for AIDS wasting syndrome for
a mere $6 thousand per month per script.
Did we really consider older and established
agents before prescribing all that Celebrex®?
Use of generic drugs can produce enormous
savings. A 30-pill bottle of generic atenolol
costs $6.99 compared to brand name
Tenormin® at $36.57. Are 30 pills of
Zocor® at $66.94 really that much better
than generic lovastatin at $36?
These examples of high cost items are har-bingers
for some of the challenges we will
face as new drugs become available over the
near future. No one wishes to balance our
state budget on the backs of the most vul-nerable
in our society but there is room for
From NCDHHS Division of Medical Assistance
As Stewards of the Medicaid Budget, We Can Do Better!
David H. Gremillion, MD, FACP
N.C. Medicaid DUR Board Member
President, Wake County Medical Society
Dr Gremillion
improvement in our fiscal management of
this precious pharmaceutical resource. Any
physician with practice experience recog-nizes
that although the new agents with
fancy attributes and the glossy promotional
brochures are exciting, they are also costly
and relatively unknown in the post market-ing
or practice environment. How well we
remember such examples as Omnifloxin®,
which was released to great fanfare only to
be removed from the market precipitously
eight weeks later with unanticipated hemol-ysis.
Our experience tells us that some of the
tried and true agents are not only equal to
the newly released products but superior in
many ways since the toxic profiles, side
effects, and prescribing nuances are well
known. These agents often provide equal or
even superior therapeutic benefit at dramat-ically
reduced cost. As physicians, we are in
the unique position to have an immediate
impact on the state Medicaid budget by con-scientiously
and thoughtfully prescribing
medications that are needed, but with a care-ful
awareness of the cost issues.
W. Pories
etc etc etc
2001 Medicaid Pharmacy Costs
Approximately one-sixth of the expenditures
for the entire Medicaid program in North
Carolina were for pharmaceutical drugs.
Eleven classes of drugs accounted for over
50% of that cost. The top six drug classes
and expenditures are cited below.
1. Gastric Acid Secretion Reducers:
$97,817,941 for 9.7% of total
expenditures
2. Anti-Psychotics (atypical, dopamine,
and serotonin):
$83,599,968 for 8.3% of total
expenditures
3. Anticonvulsants:
$50,019,568 for 4.97% of total
expenditures
4. Selective Serotonin Reuptake
Inhibitors:
$47,972,910 for 4.77% of total
expenditures
5. Analgesics/Narcotics:
$45,344,908 for 4.5% of total
expenditures
6. NSAIDS/COX Inhibitors:
$44,877,835 for 3.5%
of total expenditures
No. 3 2002 19
Risk Management - 2002
20 NCMB Forum
Annulment:
Retrospective and prospective cancellation of the
authorization to practice.
Conditions:
A term used for this report to indicate restrictions
or requirements placed on the licensee/license.
Consent Order:
An order of the Board and an agreement between
the Board and the practitioner regarding the
annulment, revocation, or suspension of the
authorization to practice or the conditions and/or
limitations placed on the authorization to practice.
(A method for resolving disputes through infor-mal
procedures.)
Denial:
Final decision denying an application for practice
authorization or a motion/request for reconsider-ation/
modification of a previous Board action.
NA:
Information not available.
NCPHP:
North Carolina Physicians Health Program.
RTL:
Resident Training License.
Revocation:
Cancellation of the authorization to practice.
Summary Suspension:
Immediate temporary withdrawal of the autho-rization
to practice pending prompt commence-ment
and determination of further proceedings.
(Ordered when the Board finds the public health,
safety, or welfare requires emergency action.)
Suspension:
Temporary withdrawal of the authorization to
practice.
Temporary/Dated License:
License to practice medicine for a specific period
of time. Often accompanied by conditions con-tained
in a Consent Order. May be issued as an
element of a Board or Consent Order or subse-quent
to the expiration of a previously issued tem-porary
license.
Voluntary Dismissal:
Board action dismissing a contested case.
Voluntary Surrender:
The practitioner’s relinquishing of the authoriza-tion
to practice pending an investigation or in lieu
of disciplinary action.
NORTH CAROLINA MEDICAL BOARD
Board Orders/Consent Orders/Other Board Actions
May - July 2002
DEFINITIONS
ANNULMENTS
NONE
REVOCATIONS
NONE
SUSPENSIONS
TALLEY, Joseph Harold, MD
Location: Grover, NC (Cleveland Co)
DOB: 4/20/1937
License #: 0000-15270
Specialty: FP (as reported by physician)
Medical Ed: University of Virginia (1963)
Cause: Following a hearing on March 21-23, 2002, the Board found
Dr Talley failed to perform adequate physical or objective
examinations in order to evaluate or diagnose patients’ com-plaints,
that he failed to perform follow-up physical examina-tions
to rule out or confirm the causes of pain prior to insti-tuting
or continuing opioid therapy, that he failed to inquire if
his patient has received medications from other physicians or
sources when he knew or had reason to believe the patient had
a history of abusing drugs, that he failed to monitor patient
compliance with the prescribed thera